Sarky - RVP

7/28/2019 Sarky - RVP

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7/28/2019 Sarky - RVP


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7/28/2019 Sarky - RVP


7/28/2019 Sarky - RVP


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This video is intended for Doctors ONLYفق

7/28/2019 Sarky - RVP


Here are some tips before you start

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Tips

• RVP is very useful and very serious.• If you are careful enough, it will become a piece of cake with

time!• In the first few RVPs, an anesthetist should be around (they

know it better).• Practice being talkative and funny. It is necessary to help the

patient overcoming the pain associated with RVP.• In the first RVPs select your patient carefully.

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TipsThis is the ideal patient for a beginner doctor:

• A young patient, but not very young (e.g. 40s but not 20s)• A patient who is generally fit (no cardiac, pulmonary or serious

systemic disorders).• A patient who has a very serious local foot problem, preferably

one who has been advised to have below or above kneeamputation. These patients tolerate pain of RVP much betterthan others because they have a stronger motivation.

• A patient who has severe pain in the foot (ischemic orneuropathic) as these patients will have better complicanceafter the pain is abolished by RVP.

• A patient who has a stronger family support, as these patientswill have better overall results.

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What does “RVP” stand for?

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RVP = Retrograde Venous Perfusion

It is a therapeutic method where aperipheral vein is used to provide the limb

with necessary medications instead of the

Artery.

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Eighty years later (1988), it was re-discovered as apotential therapy for foot disorders by Ferreira fromBrasil.

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Many doctors around the world used RVP forfoot problems (infection, ischemia, ulcers ..etc).

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In 1997 Dr Sarky presented his results of RVP in “International Surgery”, the official journal of the “International College of Surgeons”.

Since then, Dr Sarky became the world’s leaderin this technique.

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What are the scientificbasis for RVP?

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Injection into the vein increased venous HP

filtration, i.e. reversal of normal venous capillary

function.

The degree of filtration is a function of pressure

difference. Larger volume of injected fluid higher venous HP more filtration.

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Is RVP really effective?

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RVP results in high tissue concentration

of administered drugs.

Tissue concentration of 99 mTc labelled human

serum albumin after RVP was:

. 3 times higher than after intra-arterial

. 7 times higher than after systemic i.v. injection

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When is RVP a must?

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• Severe acute infections – Diffuse, with no definite localization.

– Anerobic.

– Intense necrotizing reactions or secondary gangrene.

• Critical limb ischemia– Only for occlusions below the knee

– Only when surgical intervention is not feasible• Long, tight occlusions with no distal run-offs

• Refusal of the patient.

• Complicated peripheral neuropathyWhen medical treatments gives no effects.

– Recurrent ulcers.

– Severe intolerable pain.

– Charcot disease.

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When is RVP considered

as an adjunctive therapy?

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• Complementary to surgery for allother conditions that require surgicalintervention.

• Chronic non-healing wounds andulcers.

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When is RVP better avoided?

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• Severe systemic disorders

– Advanced cardio-pulmonary disease.– Multiple organ-system failure.

• Psychological or emotional instability

• Rapidly progressive local disordersWhen RVP is not associated with rapid control of disease

threat of patient’s life (here amputation is a must).

– Expanding gangrene

– Infection extending to or above the knee.

– medical treatments gives no effects.

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What is the value of RVP?

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85% of amputations for diabetic foot are avoidable

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Direct access to sick tissues

RVP bypasses blocked arteries and delivers medications intotarget tissues despite the blocked arterial system. Patients withPAD benefit the least from medications because diseased limbgets the least amounts of the drugs.

RVP also focuses drugs into lesions more than 3 times betterthan neighboring tissues of the limb. This is due to the “rinsingeffect”.

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Beating the time factor

RVP allows a superdose (very high concentrations) of drugs intarget tissues over a very short time dramatic effects(infection control, ischemia combating, healing of wounds etc).

The rapid effect versus time • Preventing continuous damage by pathology.• Avoiding patient’s non-compliance or negligence.• Avoiding side-effects of long-term use of medications.• Reduction in costs.

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Avoiding systemic effects of drugs

RVP avoids systemic side-effects and toxicity of some of theused drugs by focusing them into target tissues. Also, when thedrug is expensive, it is not wasted on healthy organs.

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How can I do RVP?

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Requirements

1) One doctor, aware of the procedure.2) Two trained assistants.

• One for observing cuff pressure and control timing.• One for assisting in simultaneous intervention.

3) Room, wide and equipped.4) Bed, better designed for elevation of foot side.5) Special cuffs: long, wide, double inflated parts.6) Blood pressure device.7) Blood sugar meter.8) Tourniquet.

9) Syringes (10 and 20 cc).10) Canulas (22, 24).

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Evaluation of the patient

1) Psychologically, mentally, consciousness.

2) Cardio-respiratory status.

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Venous access, 1

Site• Away from the wound.• Protected area.• Not over a joint.• Most distal (forefoot is best).

How to find a vein?• Direct vision• Groove feeling• Proximal cuff at 50 mmHg• Dependency• Blind (!)

• US

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Venous access,2

• Tip check inject advance.

• Saline injection• Securing the cannula in place.

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Vital signs

BP: Abandon when systolic pressure is > 200RBS: when <200, juice is given first.

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Elevation of lower limb

How high?To a level above the head.

How long?5-10 minutes.

Factors to consider• In ischemic patients, this pain

(compensate by tourniquet)• In cardiac patients, this

discomfort.• For deep lesions, larger angles and

longer time are preferred.

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Cuff application

SiteMid-thigh, calf or both.

Type of cuff Long, to suite large thighs.Double inflatable system (for rapidresponse if leakage occurs).

Method

Inflatable part is medio-posterior.Adhesive tape surrounds the cuff.

TestingCuff is inflated to 300 mmHg to testpatient’s tolerance to discomfort.

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Preparing Injected fluids

Amount120-260 cc saline, depending on:• Size and age of the patient.• Cardiovascular status.• Syringe back-flow during injection.

• Number of drugs used (the more the more).

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Preparing Injected fluids

Drugs: Lignocaine and anticoagulant are basic +

• Infection: proper antibiotic.• Neuropathy: DSE, corticosteroid• Ischemia:

• DSE (angiogenic, oxygen saturator, insulin-like).• Ascorbic acid (anti-oxidant, acidifier).

• Mannitol (rheo-modifier).• Pentoxyfylline (rheo-modifier).

• Lowers blood viscosity.• Improves erythrocyte flexibility.• Increases leukocyte deformability.• Inhibit neutrophil adhesion and activation.

• Erythropoietin (angiogenic).• Non-healing wounds: as above + amino acids, vitamins, minerals.

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Tournique

Rarely required, for:• Congestion despite elevation.• Surgical intervention, to ensure dry field.

• Therapy of deep disorders (bones).

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Inflation

While the limb is elevated, to 300 mmHg.Then the tube is locked.

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Lowering the limb

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Injection

Order• Start with Lignocaine• Alternate others• End with heparin.

SpeedThe higher the risk, the slower the speed.

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Observation

• Vital signs q 5 minutes

• Degree of consciousness• Attitude• Talking with the patient to pick any deterioration rapidly.• Tolerance to cuff pressure.• Symptoms of lignocaine toxicity: cirumoral numbness

and tingling, tinnitus, chest oppression ..

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Manipulation

Surgical intervention or wound dressingis done as planned.

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Deflation

After a minimum of 25 minutes and a maximum of 60

minutes (longer durations are better avoided).

Preceded by a final measuring of vital signs.

Pressure is released very slowly, particularly in the

subdiastolic range of pressure.

When surgery is associated, release is made a bit faster inthe subdiastolic range to avoid excessive bleeding, nulessthis constitutes a risk to the patient.

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Post-procedural Observation

Duration30 minutes after RVP.120 minutes, when surgery is associated.

ParametersThe same as observation during the procedure + watching for

bleeding from the wound.

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How many times will RVP be required?

General rule

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RVP is repeated daily until the target is reached, e.g.• Infection: clinical evidence of control of infection

• No more fever.• Less or no pain.• No clinical manifestations of sepsis (malaise, disturbed consciousness).• No septic discharge of the wound.

• No foul smell in anerobic infection.• No progressive sloughing of tissues.• No extension of infection proximally.

• Ischemia: clinical evidence of improved arterial perfusion to the level of safety• No extension of gangrene after testing surgical intervention.• Appearance of line of demarcation.

• Appearance of granulation tissue.• Less sloughing.• Less pain.• Hyperemic wound.• Bleeding surfaces.• Improved capillary circulation of skin.• Spontaneous separation of sloughed parts.

• Neuropathy

• Restored sensations.• Better ability to walk and ascend the stairs.• Less pain to tolerability level.

Estimated number of sessions• Infection: 3-5

• Ischemia: 10-15• Neuropathy: 5-7

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Can I be a diabetic foot doctorwithout practicing RVP?

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7/28/2019 Sarky - RVP


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Sarky - RVP