Workshop book for sir 2012 justin


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Workshop book for sir 2012 justin

  1. 1. Patient Care I: Pre- and Post-Procedure Evaluation Coordinator: Laura Findeiss, MD FACULTY Justin McWilliams, M.D. Brooke Spencer, M.D. Sanjay Misra, M.D. Bairbre Connolly, M.D. Rahul Patel, M.D.______________________________________________________________________Top 10 Tips for General Patient Care 1. Focus on performing disease-specific history and physical exam to answer the basic question: does this patient need the procedure being considered 2. Keep alert for hints at other significant medical issues that may require alternative care or referral on to another specialist. If alternative care is required, take the initiative. Discuss with the referring physician and offer to initiate the required referral. 3. Be conscious that your recommendations serve the needs, desires, and lifestyle of that specific patient. Listen to the specific concerns of your patient and tailor care to them. 4. Thoroughly explain to the patient and/or family what your recommendation is and why. Include a discussion of alternative treatments. 5. Perform outpatient evaluations at a dedicated time in a dedicated location. Do not squeeze these visits in amongst procedures. 6. Chart or dictate your encounter immediately so that your representation of the encounter and plan are accurate. 7. Include a letter or call to the referring physician at the time of completing your documentation to let them know your plan and thank them for the referral. Continue to communicate your ongoing plan as you follow the patient post-procedure. 8. See patients in the office at regular intervals until there is likely no further need for your care. This may be for many years. 9. Take responsibility for prescribing medications appropriate to the care you’re providing. Again, alert the referring MD to any changes in medications that you make. 10. Take responsibility for the post-procedural management and care of your patient, both on an inpatient and outpatient basis. You understand better than the referring physician what the particular concerns may be. Make sure to communicate to the patient and the referring physician what the expected post-procedural course is and what deviations from this expected course are concerning.This workshop will cover pre- and post-procedural evaluation of interventional radiology patients with 5different disease entities, as well as discussing particular characteristics of the pediatric IR encounter. Thedisease entities discussed will include: Liver cancer (primary and metastatic) Uterine fibroids Venous insufficiency Renal artery stenosis Peripheral arterial diseaseCertain elements of clinical care are universal, and general considerations in pre- and post-procedural careare discussed below:
  2. 2. Interventional Radiology history and physical exam:The VIR H&P is often performed in the context of a consultation from another MD, and warrants a highlevel of focus on the chief complaint or reason for referral. The patient interview should focus on specificsof the presenting problem, but should contain required elements for appropriate coding. It is helpful tohave a template for each of several commonly seen problems to help keep you on track and ensure thatrequired information is collected.Ideally, templates for outpatient encounters will allow you to prospectively capture data, such as painscores, that will help you to assess progress or benefit in follow-up. Such data capture is especially helpfulfor evaluating subjective complaints as in patients with uterine fibroids, claudication, and venousinsufficiency.The physical exam should similarly focus on the signs and symptoms of the disease process beingevaluated, and need not be comprehensive in most instances. However, particular attention should be paidto any findings that may be peripheral to the chief complaint, but are relevant to the procedure beingconsidered, such as identifying a heart murmur in a patient who may undergo sedation, or evaluatingfemoral pulses in patients undergoing transarterial embolization.Inpatient consultation:These consults are often performed on an urgent or emergent basis. However, particularly in complexcases, it is imperative to document the history, physical exam, relevant data, and decision making processthat leads to an intervention, as well as documenting the content of a consent discussion with the patient orrepresentative.Sedation:Since most interventional radiology procedures are performed with moderate sedation, it is important toevaluate patients prospectively for the appropriateness of sedation. Things to consider are: patient’spsychological ability to tolerate the procedure with sedation; the degree of pain expected with theprocedure; patient baseline pain scores which, if elevated, may compromise the ability to provide adequateanalgesia; patient baseline medication regimen which, again, may make performing moderate sedationdifficult with standard medication doses; any previous sedation complications or intolerance; presence ofsleep apnea or other potential airway compromise; presence of any factor that may make managing theairway difficult in an emergency. If a patient has one or more confounding factors and the procedure isexpected to be painful, it may be appropriate to consult anesthesia to improve the likelihood of a goodpatient outcome and experience.Post-procedural assessment:Immediate post-procedural patient survey should take place in the procedure room. Assess patient’s painlevel, level of alertness, vital signs, pulses if appropriate, and access site for bleeding, hematoma, or othercomplication. If the patient is an inpatient, the referring service should be contacted to communicate thefindings or outcome of the procedure, and to communicate any concerns and the expectations for post-procedural care. Any new medications should be ordered or initiated at this time. Before the patientleaves the department, either to the patient care floor or to home, final patient assessment should beperformed and documented by a member of the IR team.Depending on the procedure, post-procedural rounds should be performed on inpatients within 24 hoursand as long as is relevant for patient care. Expected clinical course and care expectations should bediscussed with the patient’s nurse. In patients requiring outpatient IR follow up, this need should becommunicated to the referring team as well as to the patient, and arrangements should be made before thepatient is discharged.The following items should be assessed as part of the post-procedural rounds: o Access site – any evidence of bleeding, drainage, hematoma, erythema or irritation, bandages appropriate and dry.
  3. 3. o Drains or tubes – remain appropriately positioned, quality and quantity of output, dressings intact and dry, any leakage from drain site, drainage system as ordered (gravity, suction, sump, etc)o Systemic – fever, chills, rigors, nausea or other complaintso Pain – it is important to effectively manage procedure related pain. If pain is not controlled with PRN medications, a PCA should be ordered. Consider non-narcotic alternatives in patients without contraindications as a useful adjunct to traditional pain medications. Remember to order appropriate PRN medications along with opiates, such as antiemetics or antihistamines.o Complications – Direct your examination to potential procedure-specific complications and actively assess for and chart presence or absence of these.o Nursing – appropriate medications given, foley catheter out if relevant, appropriate charting (drain outputs, etc.), activity level appropriate (bedrest, limb immobilization, ad lib, etc.), diet.
  4. 4. Specific Disease Entities:Liver cancer:Top 10 tips for pre- and post-procedure clinic management for liver cancer 1. Have your staff call the patient the day before the clinic visit, to remind them of the time and place, and to bring their medication list, outside films, and names/contacts for outside physicians. 2. Allow 1 hour for a new liver cancer patient consultation; use a good clinic visit template to allow appropriate E&M coding (example in workbook). 3. Examine the imaging yourself. Evaluate tumor size, number, liver segments involved, arterial anatomy, portal vein status, bile ducts, ascites, presence of extrahepatic disease. Consult with your abdominal imaging experts in tricky cases. 4. Performance status is a very important prognostic indicator. Know the ECOG score of all your patients, and do not perform procedures on patients with ECOG of 3 or higher. o ECOG 0: Fully active o ECOG 1: Restricted in strenuous activity but ambulatory and capable of light work o ECOG 2: Ambulatory, can do self-care but can’t work. Out of bed >50% of waking hours. o ECOG 3: Limited self-care, confined to bed or chair >50% of waking hours o ECOG 4: Completely disabled, no self-care, totally confined to bed or chair o ECOG 5: Dead 5. Take time to explain the disease, prognosis, and treatment options (IR and non-IR) to patients on their initial visit. You will probably be the first to do so, and patients and their families appreciate it. Recommend surgical consultation on patients who appear to be surgical candidates. 6. Keep a database of your cancer patients, including basic information, procedures performed (with dates), last clinic visit, last imaging results, and action items/plan. Refer to the database every month or so to make sure patients are getting the follow-up they need. 7. Doing nothing is an option. Don’t let aggressive family members push a patient into treatment if the patient doesn’t want it. Be sure to ask the patient what he/she wants. 8. Schedule the labs, imaging and follow-up clinic visit on the same day; patients really appreciate this, especially those from out of town. 9. Keep the patient’s oncologist and primary doctor in the loop. Have your clinic notes faxed or mailed to these physicians, and call or email the referring physician with any important updates or questions. 10. Keep in mind your goal of therapy. If downstaging to surgery or OLT, OK to be aggressive. If bridging to transplant, the goal is tumor control, not necessarily complete elimination. If palliation only, consider strongly the patient’s clinical status and response to therapy before committing to further treatments.
  5. 5. Tips for the Interventional Oncology Consultation:PRE-PROCEDUREAt our institution, the process starts with a requisition arriving in radiology, or a page, email or phone callfrom the oncologist, asking if a patient might be a candidate for locoregional therapy. -If the requisition is faxed or sent to radiology, the scheduler will assemble the requisition, the patient’s most recent labs, and any recent clinical notes, and either present them as a packet to the IR physician, or email the packet as a PDF to the IR physician. -If I am directly called/paged/e-mailed by the oncologist then I look these items up myself .If on initial review the clinical story, imaging and labs seem appropriate for locoregional therapy, then Iemail my clinic staff to arrange an office visit +/- further imaging and labs. -I try to respond to any requests within 24 hours (the referring physicians seem to appreciate the prompt response) -On this email I cc the referring physician and their clinic manager/NP, both to keep them “in the loop” and also so that their office can begin obtaining authorization for the clinic visit and the expected procedure (this may work differently at different institutions). -In most cases, I have a good idea what procedure will likely be the most appropriate for the patient, and so I will go ahead and cc the appropriate scheduler on the same email, to schedule a treatment date. -I prefer to have either a dual-phase abdominal CT or multiphase abdominal MRI within the last month (max 2 months) to accurately depict the tumor burden. Imaging of insufficient quality should be repeated even if recent. Patients at our institution also have chest CT and bone scan to exclude extrahepatic disease. -Any patient who may be an ablation candidate has a targeted ultrasound scheduled for the same time as the initial clinic visit. After the tech does the scan, I personally scan the patient to ensure that I can see and target the desired lesion(s), as well as determine the best patient position for the procedure.The clinic visit itself takes place in our dedicated outpatient clinic area. I dedicate one day per week forclinic; when necessary I also see patients in between procedures on my procedure days, but I find that waittimes are sometimes excessive when I get stuck in a procedure. -For most initial consultations, I schedule 1 hour for the visit; pre-TACE visits usually take somewhat less time since in-office ultrasound is not needed -I schedule labs (CBC, BMP, LFTs, PT/PTT/INR, AFP/CEA) to be drawn in our lab prior to the office visit, or in the patient’s home city if more convenient for them; the scheduler should ensure that the labs are available by the time of the office visit. -Outside imaging is scanned into our PACS system, or brought with the patient on CD when that is not possible -The patient is seen initially by a fellow or nurse practitioner, who takes vitals, obtains the relevant history, and performs the physical exam (see H and P template)
  6. 6. -The fellow or NP then presents the case to the attending in clinic, who then reviews the imaging and labs, and returns to the patient room for further discussion of the findings and treatment options -Once a treatment plan is determined, a worksheet is filled out to ensure everything is prepared for the procedure (see RFA worksheet), including cardiology clearance, type of anesthesia, type of admission needed, immediate post-procedure imaging, etc.Clinic visit itself:History of present illness: This should be targeted to two main topics – the underlying liver disease, ifpresent, and the liver cancer itself. 1. Underlying liver disease: a. Hepatitis B or C, alcohol, autoimmune hepatitis, hemochromatosis, NASH? HCC less likely with PBC and PSC. b. Cirrhotic or non-cirrhotic? Consider surgery in non-cirrhotics, consider transplant in cirrhotics. c. History of ascites? Variceal bleeding? Encephalopathy? Establish Child class. d. Activity level? Establish ECOG score. 2. Liver cancer: a. Size? I tend to use ablation alone for lesions under 3-4 cm (usually RFA for small lesions and microwave for lesions at the high end of this range). I consider combined TACE/ablation in lesions up to 5 cm or so. For lesions >5 cm, I usually start with TACE, and consider ablation later if I am able to sufficiently shrink the tumor. b. Number? Consider ablation if number of lesions is not excessive (I have ablated up to 4-5 lesions in one setting when they are small in the setting of good liver function) c. Encapsulated or infiltrative? I have found infiltrative lesions to be more difficult to treat by any modality. If using ablation, I try to achieve a wider margin for infiltrative lesions than I do for encapsulated lesions. Same goes for metastatic lesions, which do not benefit from the oven effect the way HCC does in cirrhotic livers. d. Location (subcapsular, intraparenchymal, hilar)? Hilar lesions I usually do not treat with ablation, though sometimes a combination of heat-based and ethanol ablation can be performed safely; alternatively, nasobiliary tube placement with circulation of chilled saline can help protect the bile ducts for thermal ablation. Subcapsular lesions I will consider for ablation if I am able to access the tumor through some normal liver; I try to avoid direct puncture of the tumor due to bleeding/tumor seeding risk. Bowel can usually be displaced using hydrodissection techniques. Intraparenchymal lesions usually are usually the safest/easiest to treat. e. Distribution (left lobe or right lobe or both)? With arterial treatments, I usually treat only one lobe or the other at any one time. In some patients with normal liver function and a lesion in each lobe, each of which can be superselectively treated, I may treat both lobes in one setting. With ablation, I often treat tumors in both lobes at the same setting, if their liver function allows it. f. Biopsy proven? Often needed for metastatic disease, but rarely needed for HCC, where imaging is often diagnostic (use AASLD criteria) g. Prior treatments? If the patient has had prior locoregional therapy, inquire to the side effects and tolerance to help guide your therapy. Regarding Nexavar, some physicians stop it in the peri-procedural period, as it may increase arterial dissection
  7. 7. risk during arterial procedures. Others like to continue Nexavar in hopes that it will reduce the angiogenic effect of ischemia at the time of TACE. h. Symptomatic? Tumor pain is a bad prognosticator.Past medical history: Particular attention to 1. CAD (cardiac clearance) 2. CHF (doxorubicin toxicity) 3. diabetes (avoid steroids, higher risk of contrast-induced nephrotoxicity, less response to PV embo) 4. HTN (arterial puncture) 5. renal disease (hepatorenal syndrome?) 6. Other cancers?Past surgical history: 1. Prior liver surgery may increase risk of biliary related complications from embolization procedures 2. Roux-en-Y or other hepaticoenteral anastomosis increases infection risk of locoregional therapies; if locoregional therapy is required, the elevated risk is explained to the patient, and if treatment is performed, long-term antibiotic therapy is instituted (perhaps 6-8 weeks) 3. Orthopedic hardware may affect placement of grounding pads for RFAMedications: 1. Nexavar – may consider discontinuing in periprocedural period 2. Dosages of diuretics and lactulose may indicate severity of ascites/encephalopathy. 3. Other medications may suggest medical problems that the patient may have forgotten to mention in the PMH.Allergies: Self-explanatory.Social history: Especially alcohol use, encourage cessation. No drug or alcohol use if liver transplant beingconsidered. Determine the support network the patient has; is there someone to drive the patient to andfrom the hospital, to tend for them after hospital discharge, etc?Family history: Usually noncontributory, with the exception of hemochromatosis, familial polyposissyndromes, etc.Review of systems: 1. Active infection or other acute illness “how have you been feeling lately, in general”? 2. Ability to conduct usual activities. Fatigue? Weight loss or gain? 3. Liver related symptoms, as above. 4. Other ROS important to elicit: o Chest pain? o Shortness of breath? o Hematemesis? o Blood in stool? o Diarrhea/constipation? o Nausea/vomiting? o Urinary retention? o Muscle weakness? o Anxiety or depression?Physical Exam: Particular attention to vital signs, heart rhythm/murmurs, abdominal pain/ascites, breathsounds, pulses (for arterial procedures)Labs: Routine labs for liver patients include CBC with platelets, BMP, LFTs, PT/PTT/INR, and AFP/CEA.The most important labs to me include: Hemoglobin level (anemia and tolerance of possible procedural blood loss)
  8. 8. Platelet count (risk of bleeding, need for platelet transfusion, and indicator of cirrhosis severity) Creatinine (tolerance of contrast dye and gadolinium) INR (risk of bleeding, need for FFP transfusion, indicator of cirrhosis severity) Total bilirubin (liver function; I usually avoid locoregional treatment in patients with TB >3.0, though exceptions are sometimes made for select patients needing a small ablation or superselective TACE) Albumin (nutritional status and liver functional status) AST/ALT (ongoing liver injury)Imaging: I usually use Eovist MRI for liver patients, both in initial evaluation and follow-up. In myexperience, I have found that it is more accurate for diagnosing liver lesions (dysplastic nodule vs. HCC,etc) and is more sensitive to early recurrence compared to CT. If MRI is contraindicated or not tolerated,then I use dual-phase contrast-enhanced CT, which is perfectly adequate in most situations.POST-PROCEDUREAfter the procedure, patients go to the recovery area (for ablations and Y90) or admitted directly to theirinpatient/observation room (for TACE).Post-RFA orders -Vitals checks and puncture site inspection -Vicodin prn, + prn IV narcotic analgesia if needed -At our institution, MRI is performed several hours after the procedure, to verify complete ablation, confirm lack of complications, and serve as a new baseline -Patient is usually discharged after the MRI, if their pain is controlled and vitals are stable. -Patients are sent home with a prescription for Vicodin and a 5-7 day course of antibiotic (usually Cipro)Post-TACE orders -Vitals checks and puncture site inspection -Flat in bed x2-6 hours (depending on closure) -Dilaudid PCA for analgesia -Zofran prn for nausea -IV fluids (depending on heart function and fluid status, but usually 250 cc/hr for 4-5 hours) -Monitor urine output -D/c Foley in AM -AM labs: CBC, BMP, LFTs -About 70% of patients go home the next day, with most of the remainder going home on the day after that -Patients are sent home with a prescription for Vicodin and Cipro and/or Flagyl to complete a 7- day courseAfter discharge, we instruct the patients to follow up with their oncologist in 1-2 weeks, to monitor theirrecovery and keep the oncologist “in the loop”I follow up my patients 1 month after any locoregional treatment, with labs (CBC, BMP, LFTs, AFP/CEA)and imaging (usually Eovist MRI) on the same day. They get their labs and imaging and then come directlyto clinic. -H and P is performed usually by fellow or NP, focusing on the tolerance and side effects of treatment, any persistent pain or nausea, and the patient’s energy level. Any new health problems, unexpected hospitalizations, and new medications are reviewed. -After presenting to the attending, the films and labs are reviewed together and then discussed with the patient, and a treatment plan is determined.
  9. 9. -If further locoregional treatment is indicated, this is arranged for 2-4 weeks after the clinic visit(6-8 weeks after the last treatment)-If there is no evidence of residual disease, patients either are followed by IR clinic with imagingand labs q3 months, or are discharged to their oncologist who will follow them in their clinic withimaging and labs q3 months-For patients who no longer see me in clinic, I keep them in a database that I monitor every monthor so, to make sure they are getting their imaging and that no recurrence is detected (some of thesepatients are “lost in the system” and don’t follow up with their oncologists as instructed)-For patients whose tumor burden, liver disease, treatment intolerance, or clinical statuscontraindicates further locoregional treatment, I usually discharge them from the clinic back totheir oncologist. If the patient may be a candidate for further therapy but has not adequatelyrecovered from the last procedure, I will schedule a repeat IR clinic visit in 1-3 months to re-assess, depending on the nature of the problem.
  10. 10. H&P TemplateInterventional Oncology Initial ConsultationPatient Name: __________________________ MRN: _____________ Age: _________Chief complaint: _________________________ Referring MD: _____________ Date: ________History of present illness: Need 4 or more elementsUnderlying liver disease: • Hep B • Hep C • Alcohol • Autoimmune • NASH • Other:•Non-cirrhotic •Cirrhotic History of: • Ascites • Encephalopathy • Variceal bleeding Biopsy-proven? •Yes •No Tumor pain? •Yes •NoPrior treatments:Past medical history:CAD •Yes •No CHF •Yes •No Diabetes •Yes •No HTN •Yes •No CRI •Yes •NoPast surgical history: • Prior liver surgery: _______________________ • Hepatoenteric anastomosisMedications:Allergies:Social history:Occupation: ____________________ Marital status: ______________Tobacco use: ____________________ Alcohol use: _______________ Illicit drugs: ___________Family history: • Noncontributory or ______________________________________________________Review of systems: Need 10 systems Felt unusually tired? • No •Yes Abdominal pain? • No • Yes Weight loss or gain? N/V/D/C? Bloody stool? Had eye or vision • No • Yes Sad or depressed? Overly • No • Yes trouble? anxious? Hearing trouble? Dental • No • Yes Problems with joints or • No • Yes problems? Hoarseness? muscles? Coughing, wheezing or • No • Yes Skin changes? Lumps, • No • Yes shortness of breath? lesions, rashes? Chest pain or tightness? • No • Yes Problems with urination? • No • Yes Palpitations/fluttering?
  11. 11. Vital signs: Temp _____ HR _____ BP _____ RR _____ Weight _____Physical Exam: Need 8 systems General: • Well-appearing • Obese • Frail • Cachectic • No distress Skin: • No jaundice • No rash or ulcers HEENT: • PERRL • No icterus • Mucous membranes moist Respiratory: • Normal respiratory effort • Clear to auscultation bilaterally Cardiovascular: • Normal heart sounds • No murmurs, gallops, rubs Abdomen: • Nontender • NABS • No hepatosplenomegaly • Distended • Caput medusa Extremities: • No edema • Normal pulses Neuro/Psych: • Alert and oriented to person, place, time • Normal affect • AsterixisLabs: WBC____ Hgb____ Plt____ INR____ Creat____ TB____ AST____ ALT____ Alb____ AFP ____Imaging: • Personally reviewed:Size of largest tumor: ____ No. of tumors: ____Distribution: • Left lobe • Right lobe • BothNature: • Encapsulated • InfiltrativeLocation: • Subcapsular • Parenchymal • HilarAssessment: Child-Pugh score: ____ (Albumin <2.8, 2.8-3.5, >3.5; TB <2, 2-3, >3; INR <1.7, 1.7-2.2, >2.2; Ascites none, mild, mod; Encephalopathy none, grade I-II, grade III-IV. A=5-6; B=7-9; C=10-15) ECOG stage: ____ (0=normal; 1=able to do light work; 2=selfcare ok, up and about >50% waking hours; 3=some selfcare, up <50% waking hours;4=completely disabled; 5=dead) Resection candidate? ____ (Normal platelets and bilirubin, no portal HTN, R0 resection possible) Transplant candidate? ____ (Single tumor up to 5 cm or 2-3 tumors up to 3 cm, no vascular invasion, no extrahepatic disease)Plan:Total attending time in consultation:NP/Fellow signature: Attending signature:NP/ Fellow print: Attending print:
  12. 12. Radiofrequency Ablation Check ListNAME: DATE:UCLA ID Consult Cardiology Consult No Yes Pulmonary Consult No Yes Labs CBC/Platelets PT PTT Comprehensive Metabolic Group Hepatic Order Group CEA AFPMust be done within 30 days EKG Documented @ UCLA Yes Done On: ______ On all men over 50 To Be Done @ Outside Clinic Yes And women over 60 if Platelets < 60,000 Transfusions Platelet Transfusion __ 10 Pack FFP __ Units Procedure Liver Ablation (47382) Kidney Ablation (50592) CRYO (50393) Guidance Ultrasound (76940) CT (77013) CT Guidance (77012) Renal Stent Placement (50393) Nasobiliary Tube Placement (43267) (in MPU) Post Imaging CT Abdomen/Kidney (74170) MRI Abdomen (74183) Anesthesia MAC LMA General Hospital Admission Yes Gonda (23 Hr. Hold) Yes PTU Yes Liver Biopsy (47000) No Yes Renal Biopsy (50200) No Yes
  13. 13. Uterine fibroids 38 yo with menorrhagia, no bulk symptoms 25 yo with SAB x 2, one live birth 3 years ago. Multiple large fibroids with bulk symptoms.General approach to the fibroid patient:Periprocedural management PainPost-procedure expectations: Pain Discharge Menstrual cycle BulkFollow-up Short term Long term Imaging? Pain scores BulkVenous insufficiency 50 yo female with BLE heaviness and pain, worsening throughout the day. 50 lb overweight. Nosuperficially visible varicosities. 2+ pedal edema and mild hemosiderin staining of both ankles. US showsBLE deep and superficial reflux, small varicosities from GSV. 42 yo male with ropy varicosities bilateral posterior thighs and diffusely in calves. Complains ofdeveloping painful phleboliths and occasional bleeding from varicosities. US shows large Giacomini veinboth legs with reflux and varicosities arising from them, bilateral SSV reflux and large varicosities.General approach to the venous insufficiency patient:Periprocedural considerationsPost-procedure instructions:Follow upRenal Artery Stenosis In evaluating patients for renal artery stenting, it is important to evaluate the minute details of thepatient scenario and presentation. For optimal success, patients will meet certain criteria, then be evaluatedfor the presence of stenosis based on high clinical suspicion.Elements of the workup of the patient with suspected renovascular disease include: Past med history Past surg Hx Medications – especially exact formulations and doses of all antihypertensive medications Allergies Vitals – especially bilateral upper extremity blood pressures Physical exam Labs: o BUN
  14. 14. o Creatinine o Short clearance o 24 h proteinuria Studies: o Duplex of the renal arteries and renal ultrasound for size o Echocardiogram  Consider in patients with hypertension  Mandatory in patients with pulmonary edema o 6 h or 24 h ambulatory blood pressure monitoring It is helpful to have the following values from 6 months prior to evaluate the progression of disease: o BUN, Creatinine, Short clearance, BP, number of meds with classes- (ARBs, ACEIs, B- blocker, diuretics)Periprocedural management Management of antihypertensive medications in the peri and post procedural period: hold allantihypertensives? Taper? Which classes to hold and which to continue?Signs of complications (renal artery thrombosis or perinephric hematoma)Post-procedural medication management (Plavix, etc.)Long-term follow up (duplex vs lab and BP documentation or both) – office visits how often? Duplex howoften? BP diary? Renal function eval?Peripheral Arterial Disease:Patient 1: 5 block absolute claudication distance limiting active lifestyle in 53 yo male with 35 yo wife. Nopast medical history except mild BPH. Quit smoking 7 years ago with 30 pack year history. (PE and non-invasive imaging support bilateral common iliac stenosis and left SFA long segment stenosis.)Patient 2: 67 yo female with longstanding type II DM, on insulin x 5 years. Severe diabetic peripheralneuropathy and denies rest pain or claudication. Referred for small encrustation at the distal aspect of thefirst toe that has failed to heal in 5 months in spite of PCP-prescribed antibiotic.General approach to the PAD patient:Performance of a complete initial PAD consult is an opportunity to globally affect CV outcomes in thesepatients, as well as the opportunity to find additional disease with a good thoughtful workup.Decision making in these patients regarding medical therapy vs exercise vs intervention vs surgery iscomplex, and somewhat outside the scope of the workshop, but all decision making is contingent oncomplete history and physical exam.Periprocedural management when revascularization is performed:Long-term relationship with these patients and longitudinal management: periodic exam duplex imaging when to re-intervene
  15. 15. Pediatric Interventional RadiologyApproach to the pediatric encounter:Focus on age appropriate interactions with pediatric patients and families to optimize communication: If available, involve child life specialists Use CDs and visual display Music/iphonesDuring pediatric consultations, it may be helpful to show pictures of procedure rooms to make theexperience less daunting (virtual tour at IGT Clinic visit).Important elements of the pediatric IR H&P: Prior medical Hx - include congenital Hx Don’t forget LMP and possibility of pregnancy even in young girls A special consideration in pediatric patient assessment is variation of blood values with age. It is important to be familiar with these variations for pre and post-procedural assessment.There are special considerations when obtaining consent for procedures on children, and it is important torecognize and address issues of consent vs. assent. While underage children are unable to legally consentfor procedures, even young children are able to give assent for procedures, and discussions aroundprocedures should be performed with this in mind.Sedation vs general anesthesia:Factors that may help in determining appropriateness of sedation include duration & complexity ofprocedure and maturity of patient.Use of topical anesthesia is encouraged;PALS certification & rescue are critical if planning to use sedation, as are knowledge of sedation drugs anddosages and familiarity with fasting issues & hydrationFor post-procedural pain - dosages & drugs again are different from those used in adultsPeriprocedural considerations: Temperature monitoring is particularly important in small children due to increased relative body surface area; Fluid and contrast volumes are highly relevant in small children – prospective limits of saline flush and contrast dose should be set and adhered to Similarly, it is important to plan for radiation protection. Use US for guidance when possible. Glucose and hypoglycemia: small children are susceptible to hypoglycemia when NPO. Monitor glucose and be prepared to treat hypoglycemia. It is useful to prepare and have on hand cheat sheets for various drug dosages; It is recommended to plan the procedure and equipment in advance, specific to the child’s size and age.The psychological well being of the child is an important focus throughout the processPreprinted consents and information pamphlets & discharge instructions are useful to have on hand andvery helpful to parents and kids.