1. Interventional Radiology
North Shore Medical Center
9/18/2018

2. The “Ins and Outs” Needles Catheters Guide Wires Tubes
Ya-Da-Ya-Da-Ya-Da!!!!
9/18/2018

3. Introduction
Purpose: to discuss a brief history of Interventional Radiology, the current interventional procedures done at the NSMC, the radiology nurse’s role and the impact on patient care in the Radiology Department
To educate floor and recovery room nurses about the pre and post care of the IR patient
Joyce Silvano, RN, ANM
Radiology
9/18/2018

4. Topics of Discussion Definitions and Brief History
Vascular and Non-Vascular Interventional Radiologic Procedures
Pre, Intra, and Post Procedure Nursing Care
Follow-up Care
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5. Definitions INTERVENTIONAL RADIOLOGY (IR)
minimally invasive procedures and targeted treatments using image guidance
small instruments guided through the blood vessels or other pathways to treat diseases percutaneously
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6. Definitions INTERVENTIONAL RADIOLOGIST medical doctors who specialize
and are board certified in performing
procedures using medical imaging
assume responsibility for the patient’s
care before, during, and after
the procedure
INTERVENTIONAL RADIOLOGY NURSE
critical care RN who provides continuous
quality care for the patient requiring an
interventional procedure
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7. Interventional Radiology Nurse
Patient advocate
Patient educator
Responds to medical emergencies within the entire department
1. Contrast Reactions
2. Seizures
3. Vasovagal Reactions
4. Cardiopulmonary Arrest
Liaisons – communication between radiology and patient care floors, referring facilities, or doctor’s offices
Long-term Goal: continue to provide educational opportunities to our fellow nurse’s
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9. Brief History
1967, Dr. Alexander Margulis coined the phrase “interventional diagnostic radiology”
Mid 70’s: Improved radiologic imaging
and development of tools
Balloon Catheters
Wires
Interventional Radiologists pioneered
coronary angiography, invented
angioplasty and catheter-delivered stents
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10. Brief History 1992: AMA officially recognized IR
as a medical specialty
2001: Society of Interventional Radiology (SIR)
adopted the following definition: “Interventional
radiology is the medical specialty devoted to
advancing patient care through the innovative
integration of clinical and
imaging-based diagnosis and
minimally invasive therapy.”
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11. Vascular Interventions
Angiography/Angioplasty/Stents
venous and arterial
Fibrinolytic Therapies
Embolization Therapies
IVC Filter Insertions (mostly retrievable)
Venous Access Device Insertions
Implanted VAD
Dialysis Catheters: Temporary
and Permanent
PICC and CVC insertions
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12. Non-Vascular Interventions Biliary Interventions
Percutaneous Cholangiograpy and Biliary Drainage Catheter Insertion
Cholecystostomy
Biliary Stone Removal
Biliary Strictures: Dilitations and Stent Insertions
GI Interventions
Percutaneous Gastrostomy/Gastrojejunostomy
GI Strictures: Dilitations and Stent Insertions
GU Interventions
Antegrade Pyelogram/Nephrostomy
Nephroureteral and Ureteral Stent
Renal Stone Manipulation
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13. Non-Vascular Interventions Cat Scan and Ultrasound
Biopsy and/or Fluid Aspirations
Thoracic (lung, pleural, and mediastinal)
Retroperitoneal Lymph Nodes
Hepatobiliary ( liver: focal abnormality/targeted or for liver medical disease, increased LFT’s or Hep C)
Pancreas
Spleen
GU (renal: focal abnormality/targeted; medical renal disease; bladder, urethra, prostate)
Soft Tissue (superficial or deep)
GI Mesenteric
Adrenal
Peritoneal
Muskuloskeletal (bone, joint, muscle)
Neuro-spinal
Thyroid
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14. Pleural (effusion, pneumothorax) Mediastinal Intraperitoneal (ascites)
Drainages
Abscess/Infections
Thorax – empyma
Retroperitoneal
Intraperitoneal
Visceral/Organ
Superficial
Non-Infected
Pleural (effusion, pneumothorax)
Mediastinal
Intraperitoneal (ascites)
Visceral/Organ (cyst aspiration)
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15. Drainages (continued)
Sclerosis
Thoracic
Retroperitoneal
Intraperitoneal
Visceral
Pain Management
Neuro-blockade
Vertebroplasty
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16. Interventional Radiology Nursing Care
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17. Pre-Interventional Procedures
Labs: BUN, Creat, eGFR, E-Lytes; Coags, CBC, FSBS on arrival if not done at home; urine HcG; fibrinogen and type and screen for fibrinolytic therapy; type and screen for RFA and medical renal biopsy; EKG for all PVD patients and patients receiving anesthesia
Consent/History & Physical
Nursing Assessment with Medication Reconciliation
Procedural Teaching
Pre-procedure instructions for outpatient (telephone screening if no consult)
Renal agram patients: Hold long acting antihypertensives if renal angioplasty is likely
eGFR < 60: Mucomyst 600mg twice a day 24 hours prior and on the day of the contrast and/or Bicarb drip 3 ml/kg for 1 hour prior to contrast exposure and 1 ml/kg during exposure and for 6 hours post contrast
Prior contrast reaction: Pre-medicate with prednisone and diphenhydramine
Anticoagulants: Coumadin, Heparin, Lovenox, Fragmin
Antiplatelet therapy: ASA products, Vitamin E, the 3 G’s, Fish Oil, Plavix
Site marking and patient identification outside of the procedure room
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18. Intra-procedure care Procedural Sedation when indicated
Circulator for anesthesia cases
Monitor patient continuously during procedure
Report any abnormal changes in vital signs or patient condition to the interventional radiologist
Reassure patient, explain what will happen next
Reassess patient frequently for pain, change in condition and intervene as appropriate
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19. General post-procedure care
Post-procedure instructions: patient, family member if procedural sedation used
Maintain IV access until discharged
Monitor puncture site, wound, etc. until patient transferred to nursing unit or discharged home
Reassess condition, vital signs, pain as above
Document assessments and discharge criteria on flow sheet
Handoff report to accepting floor or outside facility
Discharge instructions given to and reviewed with patient and family member (may be done prior to procedure by IR RN)
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20. IR Procedures at NSMC
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21. Diagnostic Imaging Procedures
Lumbar Puncture
2 hour recovery
Flat x1 hour
Pre procedure - No dietary restrictions; Post procedure - encourage caffeinated fluids if no contraindication
Outpatients may drive home
Myelogram
Flat x 1 hour
Pre procedure - light breakfast then clear liquids; Post procedure – same as lumbar puncture
Patient requires ride home
Discharge instructions to include time frame and symptoms of post puncture headache (slow leak may take up to 3-5 days to exhibit symptoms nausea and vomiting; unable to lift head off of pillow)
Arthrogram
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22. Renal Artery Angiogram/Angioplasty/Stent Insertion
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23. Peripheral Vascular Angioplasty/Stents
Next Steps
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24. Uterine Artery Embolization
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26. Pre-UAE
Post-UAE
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27. Other Indications for Embolizations
Arterial bleeding d/t tumor erosion
Epistaxis
AVM/Cerebral Aneurysms
Uncontrollable post-partum bleeding
Inadvertent arterial injury during surgery
9/18/2018

28. General Post Angiography Care
Arterial puncture site
Femoral stick: lower extremity extended and still x 2-4 hours with closure device; x 6-8 hours manual compression, may log roll side to side
Axillary stick: keep arm in sling and still for 6-8 hours and assess for brachial plexus injury
HOB 30 degrees
Monitor puncture site(s) for hematoma
Apply direct pressure to puncture site and call IR
Retrograde stick – Index finger on and two fingers above puncture site
Antegrade stick – Index finger on and two fingers below puncture site
CONFUSED? Middle finger on the puncture site with one finger above and one below
Monitor vascular status of the extremity distal to puncture site to include pulse checks, csm and temperature assessments
Venous puncture site
Extremity still for 2-4 hours
Monitor for signs of bleeding
Encourage oral fluid intake for those patients able to drink to help excrete contrast and prevent nephrotoxicity
DO NOT ADMINISTER PROTAMINE SULFATE FOR REVERSAL OF HEPARIN TO ANY PATIENT THAT HAS RECEIVED NPH (neutral protamine Hagedorn) INSULIN. This may percipitate an anaphylactic reaction…
Give smoking cessation information to any patient with peripheral vascular disease that continues to smoke
Encourage patient to exercise regularly
Discharge Instructions: NSMC Clinical Med Rec Froms
9/18/2018

29. Specific Angiographic Potential Post Procedure Complications
Renal angioplasty +/- stent insertion
Hypotension especially if patient takes multiple antihypertensive medications and long acting drugs have not been discontinued
Worsening renal function or failure with peripheral renal emboli (not immediately evident)
Embolization procedures
Ischemic pain distal to embolization: UAE, iliac artery (pre endo graft repair of AAA)
Misembolization
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30. Endovascular Stent Grafts
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31. Indications, Goals, Complications
Combined IR/OR procedure in OR suite
Emergent or Elective
Known or suspected rupture or rapidly expanding rupture
Less invasive alternative for low risk patient decreasing procedural morbidity & mortality; post procedural pain and complications; decrease in hospital stay (2 days low risk patient and 4 days high risk patient)
Provides treatment to high-risk patients who are not surgical candidates and would have no other therapeutic options
Major Complications
MI, CHF, Hypertension, DVT, Stroke, GI and RP hemorrhage, HIT, limb ischemia +/- amputation, pseudoaneurysm, renal failure, infection, surgical conversion
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33. Dialysis Catheters/Temporary and Permanent Hickman Pheresis Catheters
Venous Access Devices
PICC/CVC
Implanted VAD
Dialysis Catheters/Temporary and Permanent
Hickman Pheresis Catheters
9/18/2018

34. Biopsies
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35. Post Biopsy Care Lung Biopsy Abdominal/Organ biopsy
Usually FNA’s (Fine Needle Aspirations) only
CXR 1 hour and 3 hours post biopsy
Immediate CXR for chest pain, dyspnea, decreasing sats
Biopsy side down x 3 hours (may sit up to eat after 1 hour CXR)
NPO until 1 hour CXR read and is okay
Blood tinged sputum is to be expected, large amount of hemoptysis contact IR MD
Pneumothorax: Continue supplemental O2
May transfer to recovery with small, stable ptx
PTX may be aspirated prior to transfer
Abdominal/Organ biopsy
Biopsy site down x 3 hours (liver/renal)
Liver biopsy – always core sampling for non targeted biopsy
Stretching of the liver capsule may cause moderate to severe pain
Pain may radiate to the shoulder
Advance diet as tolerated
All Biopsy patients
Up to 4 hour recovery time
Assess for signs of hemorrhage or infection – Non targeted renal biopsies (core) stay 23 hours to monitor HCT’s
Discharge Instructions NSMC Clinical Med Rec Froms
9/18/2018

36. Percutaneous Nephrostomy
PCN – External drainage of the renal collecting system
Ureteral obstruction causing a hydro or pyonephrosis; tumor, pregnancy, stone.
Tract creation for lithotripsy with guide wires left in place
Urinary diversion to allow healing of ureteral leaks or fistulas
May be short term; tract for lithotripsy, decompression from infection, pre and post stent insertion (safety catheter)
May be long term; maintain drainage in patients with malignant tumors compressing the collecting system, uni or bilateral.
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37. Nephroureteral Stent & Ureteral Stent
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39. Post PCN Care Observation for up to 4 hours
Monitor for signs of retroperitoneal bleeding
Vital sign changes
Severe flank pain
Drop in HCT without hematuria
Monitor for hematuria
Blood tinged urine output expected for the first 48 hours
Gross hematuria – call MD
Forward flush catheter with 10 ml NS
Maintain catheter patency - no kinks
Observe for drainage around catheter at skin site
Decreased urine out put
Bladder Spasms
Discharge Instructions NSMC Clinical Med Rec Forms
9/18/2018

40. Vertebral Augmentation - Vertebroplasty
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41. Vertebral Augmentation Kyphoplasty
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43. Post Vertebral Augmentation Care
Flat for 2 to 4 hours
Advance diet as tolerated
Watch for signs of complications
Chest pain/hypoxemia – pulmonary cement embolus
Neurological changes – CNS cement embolism
Loss of bowel or bladder control
Lower extremity weakness
Fractured Rib
Temporary worsening of pain may occur
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44. TIPS –Transjugular Intrahepatic Portosystemic Shunt
Reroutes blood flow to reduce complications from portal hypertension and varices
Reduces portal vein pressure by creating a decompression channel between a hepatic vein and an intrahepatic branch of the portal vein
Usually done emergently because of hemorrhage from varices
May be performed electively for refractory ascites
Stent placed from portal vein directly through liver to hepatic vein
Lasts 1-4 hours
Usually done under general anesthesia
Potential Complications
Encephalopathy: toxic substances in the bloodstream are ordinarily filtered out by the liver. The TIPS may cause too much of these substances to bypass the liver filtration, so a patient who already has encephalopathy because of their liver disease may not be a good candidate for the procedure.
bleeding into and around liver
occlusion or stenosis of stent
pulmonary edema from elevated cardiac output, cardiac index and RA pressures (especially in acutely bleeding patient receiving fluid resuscitation)
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46. Radiofrequency Ablation (RFA)
Minimally invasive procedure under CT or US guidance
Special needle electrode placed in a tumor
Most often primary liver or colon met to liver, can be done for renal, lung and bone lesions
Effective treatment in patients unsuitable for surgery, failed chemotherapy, recurrence after surgery, multiple lesions
Treated in one or more sessions, minimal discomfort, outpatient procedure
Radiofrequency current passed from generator through the electrode to heat the tumor tissue near the needle tip destroying cancer cells and a small rim of normal liver tissue
Closes small blood vessels, minimizing risk of bleeding
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48. Radiofrequency Ablation (RFA)
Risks of liver RFA include brief shoulder pain, inflammation of gallbladder, damage to bile ducts with resulting biliary obstruction, thermal damage to bowel or adjacent structures
“Post-ablation syndrome” flu-like symptoms that appear 3-5 days post procedure, lasting about 5 days, treated with acetaminophen
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49. What’s on the Horizon?
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52. Hepatic Artery Chemoembolization (TACE)
Used in the treatment of
Primary unresectable neuroendicrine tumors and HCC
Metastatic colon cancer confined to the liver
Delivers highly concentrated drugs (10 to 25 times greater than systemic chemo) to the tumor itself and knocks out the blood supply
Dwell time is prolonged (up to 1 month)
85% of the drug is trapped in the liver minimizing systemic toxicity
Hospital LOS is 0 to 3 days
2-4 treatments (1 month apart) may be necessary depending on the patient’s anatomy
80% to 90% of patients experience “post embolization syndrome”: pain, fever, n&v
Severity varies tremendously from patient to patient
Can last a few hours to a few days
Patients are pretreated with antibiotics, antiemetics, narcotic analgesics and are discharged with prescriptions for all three
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55. Selective Internal Radiation Therapy (SIRT)
Radioactive microspheres, called SIR-Spheres® deliver radiation directly to the site of the liver tumors
Targeted therapy spares healthy tissue while delivering up to 40 times more radiation to the liver tumors than would be possible using conventional radiotherapy.
Generally not regarded as curative but can increase life expectancy and quality of life
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58. These singers are all Anesthesiologists in Minnesota and they can really sing. They are also funny..
Here they sing "Waking up is hard to do"                 
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63. National Radiology Nurses Day April 13, 2010
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64. Embolization is a minimally invasive means of blocking the arteries that supply blood to the fibroids.
Small particles are injected into the arteries, which results in the blockage of the arteries feeding the fibroids.
The procedure was first used in fibroid patients in France as a means of decreasing the blood loss that occurs during myomectomy (surgical removal of fibroid).
It was discovered that after the embolization, while awaiting surgery, many patient's symptoms went away and surgery was no longer needed.
The blockage of the blood supply caused degeneration of the fibroids and this resulted in resolution of their symptoms.
This has led to the use of this technique as a stand-alone treatment for symptomatic fibroids.
9/18/2018

65. Percutaneous Gastrostomy/Gastrojejunostomy
After inflating the stomach with air, two to four “tacks” are inserted through the abdomen into the stomach using a long needle and suture material.
As the suture is pulled back, a small metal tack opens and is then used to pull the stomach against the abdominal wire.
A small stab wound is then made between the tacks through which a wire and a catheter is advanced into the stomach.
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66. When a gastro-jejunostomy tube (G/J) is placed, the wire and catheter are passed from the stomach into the duodenum to the jejunum.
A MicKey™ Button is available as a G-tube, G-J tube or J-tube. The access port lies flush with the abdomen and is covered with an attached plug. An extension set is required to feed or give medications.
A balloon is inflated in the stomach with 10-20ml saline for both G tubes and G/J tubes to prevent dislodgement. A disk at the insertion site is used to prevent forward migration.
9/18/2018

67. Vertebral Compression Fractures (VCF)
700,000 VCF’s occur each year in the US.
Approx. 150,000 people are hospitalized due to pain and medical management associated with VCF’s.
Osteoporosis-related disabilities confines patients to more immobile days in bed than stroke, heart attack or breast cancer.
VCF’s occur more than hip and wrist fractures combined.
Vertebral Augmentation provides fracture stabilization and correction of spinal deformity.
Patients experience significant reduction in pain and improvement in mobility, thus increasing overall quality of life.
9/18/2018

68. Endovascular Laser Vein Ablation Vein Center - Beverly
Minimally invasive, outpatient procedure to treat varicose veins in patients with venous insufficiency complications or for cosmetic purposes
Laser energy directly into lumen of the
greater saphenous vein
Damaging endothelial layer and vein wall,
thrombotic occlusion of the vessel
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69. Endovascular Laser Vein Ablation
Initial reports: 96% or greater occlusion at 9 months with less than 1% incidence of transient paresthesias
Some degree of post-procedure discomfort and ecchymosis, no other major complications reported
Recuperation: 2-3 days
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