Patient Preparation

Dr Richard TippettIR Consultant

Dorset County Hospital NHS Trust

IRTB 2013

IRTB 2013

Objectives

• Understand the principles relating to:– Anticoagulation– Antibiotic prophylaxis– Sedation / Analgesia– Local anaesthesia

MINIMIZE RISK!

LOCAL VARIATION

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Other considerations

• Radiation protection– You– Allied staff members

• Dose reduction• Patient• Scatter

• Aseptic technique / Skin preparation

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Anticoagulation

• Warfarin / Antiplatelets / Heparin

• Elective / Urgent / Emergency• Patient co-morbidities• Risk of haemorrhage

Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image Guided Interventions

© 2012, Society of Interventional Radiology.

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Low risk cases

• Venous access, drain insertion, drainage tube exchange, IVC filter insertion

• No need for pre-procedural coagulation tests (unless on warfarin / heparin)

• INR<2.0• Continue aspirin / clopidogrel

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Moderate risk

• All angiography, most of everything else

• Pre-op clotting req’d, no platelet assessment

• INR<1.5• Platelets >50• Stop clopidogrel 5/7, continue aspirin

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High risk

• TIPSS, biliary, renal interventions and biopsy

• Check everything

• INR / APTTR <1.5• Plts >50• Stop aspirin / clopidogrel 5 days

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Warfarin

• Ideally INR < 1.5

• Emergency reversal– Vitamin K: 500mcg – 2mg often gets INR to

acceptable level. 10mg can cause problems with re-warfarinisation.

– Prothrombin complex concentrate –Beriplex.– FFP?

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Anti-platelets

• Aspirin, Clopidogrel, Dipyridamole.• Single agent regime- No indication to stop for

most IR procedures.• Dual agents- stop one (e.g. Clopidogrel) for

5/7.• Patients with drug eluting stent/carotid stent.

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Antibiotic prophylaxis

• World wide attention on drug resistant bugs• Most guidelines/ reviews extrapolate from surgical

data.• Some evidence specific to IR.• Helpful to categorise into:-– Clean– Clean contaminated.– Dirty.

Practice Guideline for Adult Antibiotic Prophylaxis duringVascular and Interventional Radiology Procedures

© 2010, Society of Interventional Radiology

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Clean

• If the gastrointestinal (GI) tract, genitourinary (GU) tract, or respiratory tract is not entered

• Inflammation is not evident• No break in aseptic technique.

• Routine diagnostic angiography.

• No prophylaxis required.• Stent-grafts?

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Clean contaminated

• If the GI, biliary, or GU tract is entered• Inflammation is not evident• No break in aseptic technique.

• Nephrostomy tube placement in a patient with sterile urine. Also UAE

• 1gm Cef

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Dirty

• If it involves entering an infected purulent site such as an abscess, a clinically infected biliary or GU site, or perforated viscus.

Prophylaxis is mandatory, adjunct to existing therapy. WATCH FOR SEPSIS

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When to administer?

• Optimal timing is within 2hrs of the procedure.

• If the AB is given 3 hours pre/post, the infectious complications are 5X greater.

• If clean, clean contaminated 1 dose lasting 6-8 hours is adequate.

• Contact your friendly Microbiologist.

Classen DC, Evans RS. Pestotnik SL. Ct al.The timing of prophylactic administration of antibiotics

and the risk of surgical wound infection.N Eng/J Med 1992:326:281-286

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Sedation / Analgesia

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Sedation / Analgesia

• Get good at it and give it!• Need to be monitored- Not by you!• Need to be fasted for 6 hours (solids + Milk)

2Hrs (Clear fluids)• Give Analgesia first then sedative 5-10

minutes later- Synergistic effects.

• PCA in complex / embolisation cases

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Fentanyl

• Particularly useful- Onset within 1-2 minutes.• Short duration of action.• Repeated doses have a longer duration.• Dose 50-200 mcg then 50mcg as required.• Does not accumulate in renal failure.

• Naloxone- 400mcg to 2mg.

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Midazolam

• Conscious sedation– Responds to non-painful stimuli.

• Maximum onset 10-15 minutes.• Dose- 2mg/ 0.5-1mg in the elderly.• Paradoxical excitement/aggression.

• Flumazenil- 200mcg over 15 secs then repeated doses of 100mcg (usually need 400-600 mcg)

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Local anaesthesia

• Topical:-– Amethocaine (Amitop) better than EMLA.– Needs to be put on at least half an hour prior to

procedure.• Injectable– Lignocaine (Lidocaine)– Lignocaine + Adrenaline (Xylocaine)– Bupivicaine (Marcain)

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Doses

• Lignocaine:-– 4 mg/KG– 1% = 10mg/ml– 28 mls of 1% for 70Kg patient.

• Xylocaine:-– 7mls/KG– 53mls of 1% for 70 Kg patient.– Anaesthetists will give more

• Marcain– Max 60mls using 0.25% solution.

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Administration

• Use smallest needle possible for the skin.• Always aspirate before injecting.• Inject slowly.• Ultrasound guided administration – encase

the target.

• Overdose – give IV lipid emulsion

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Summary

• Understand the principles relating to:– Anticoagulation– Antibiotic prophylaxis– Sedation / Analgesia– Local anaesthesia

MINIMIZE RISK!