Post-procedural Care in Interventional Radiology: What Every Interventional Radiologist Should Know-Part I: Standard Post-procedural Instructions and Follow-Up Care

Improving pain control during transarterial chemoembolization for hepatocellular carcinoma performed under local anesthesia with multimodal analgesia

PURPOSE

The purpose of this study was to assess the performance of a reinforced analgesic protocol (RAP) on pain control in patients undergoing conventional trans-arterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Eighty-one consecutive patients (57 men, 24 women) with a mean age of 69 ± 10 (standard deviation) years (age range: 49-92 years) underwent 103 cTACEs. Standard antalgic protocol (50 mg hydroxyzine, 10 mg oxycodone, 8 mg ondansetron, and lidocaine for local anesthesia) was prospectively compared to a RAP (standard + 40 mg 2-h infusion nefopam and 50 mg tramadol). The individual pain risk was stratified based on age, the presence of cirrhosis and alcoholic liver disease, and patients were assigned to a low-risk group (standard protocol) or high-risk group (RAP). The primary endpoint was severe periprocedural abdominal pain (SAP), defined as a visual analog scale score ≥30/100. A predefined intermediate analysis was performed to monitor the benefit-risk of the RAP. Based on the intermediate analysis, all patients were treated with the RAP.

RESULTS

The intermediate analysis performed after 52 cTACE showed that 2/17 (12%) high-risk patients (i.e., those receiving the RAP) experienced SAP compared to 15/35 (43%) low-risk patients (odds ratio [OR] = 0.18; 95% confidence interval [CI]: 0.02-0.98; P = 0.03). Analysis of all procedures showed that 12/67 (18%) patients in cTACE receiving the RAP experienced SAP compared to 15/36 (42%) patients who did not receive it (OR = 3.27; 95% CI: 1.32-8.14; P = 0.01). There were no statistical differences in adverse events, particularly for nausea, between groups.

CONCLUSION

Reinforcing the analgesic protocol by combining non-opioid and opioid molecules reduces perioperative pain in patients undergoing cTACE for HCC.

Complication Management and Prevention in Vascular and non-vascular Interventions

PURPOSE

 This overview summarizes key points of complication management in vascular and non-vascular interventions, particularly focusing on complication prevention and practiced safety culture. Flowcharts for intervention planning and implementation are outlined, and recording systems and conferences are explained in the context of failure analysis. In addition, troubleshooting by interventionalists on patient cases is presented.

MATERIAL AND METHODS

 The patient cases presented are derived from our institute. Literature was researched on PubMed.

RESULTS

 Checklists, structured intervention planning, standard operating procedures, and opportunities for error and complication discussion are important elements of complication management and essential for a practiced safety culture.

CONCLUSION

 A systematic troubleshooting and a practiced safety culture contribute significantly to patient safety. Primarily, a rational and thorough error analysis is important for quality improvement.

KEY POINTS

· Establishing a safety culture is essential for high-quality interventions with few complications.. · A rational and careful troubleshooting is essential to increase quality of interventions.. · Checklists and SOPs can structure and optimize the procedure of interventions..

CITATION FORMAT

· Weiss D, Wilms LM, Ivan VL et al. Complication Management and Prevention in Vascular and non-vascular Interventions. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1829-6055.

CIRSE Clinical Practice Manual

Background

Interventional radiology (IR) has come a long way to a nowadays UEMS-CESMA endorsed clinical specialty. Over the last decades IR became an essential part of modern medicine, delivering minimally invasive patient-focused care.

Purpose

To provide principles for delivering high quality of care in IR.

Methods

Systematic description of clinical skills, principles of practice, organizational standards and infrastructure needed for the provision of professional IR services.

Results

There are IR procedures for almost all body parts and organs, covering a broad range of medical conditions. In many cases IR procedures are the mainstay of therapy, e.g. in the treatment of hepatocellular carcinoma. In parallel the specialty moved from the delivery of a procedure towards taking care for a patient’s condition with the interventional radiologists taking ultimate responsibility for the patient’s outcomes.

Conclusions

The evolution from a technical specialty to a clinical specialty goes along with changing demands on how clinical care in IR is provided. The CIRSE Clinical Practice Manual provides interventional radiologist with a starting point for developing his or her IR practice as a clinician.

Audit of electronic operative documentation in interventional radiology: the value of standardised proformas

Background

On the background of the interventional radiology department of a tertiary hospital converting its periprocedural documentation from paper-based to electronic using a standardised proforma, a study was performed to ascertain the effects of this change on the standard of clinical documentation for radiologically-guided angiographic procedures. Using a retrospective approach, perioperative records were analysed in reverse chronological order for inclusion in the study. The standard for this audit was developed in the form of minimum criteria that all clinical documentation of angiographic procedures were expected to meet.

Results

The audit was performed at three equally spaced intervals of 6 months, yielding a total of 99 records. The baseline audit of paper-based records concluded > 80% completeness for 8 out of the 14 of parameters measured, with only two of parameters meeting the target of 100% completeness. The second audit cycle performed on electronic records found 7 out of 14 parameters demonstrating absolute improvement in completeness, when compared to paper-based, but with the number of parameters exceeding 80% completeness falling to only 4 out of 14. Again, 100% completeness was observed in only 2 of the parameters. In the final audit cycle, after the introduction of a standardised electronic proforma, performance improved in every dimension with 6 out of 14 parameters reaching completeness of 100% and the 80% completeness threshold met by 12 out of 14 parameters.

Conclusion

The construction of a procedure-specific perioperative electronic proforma can save clinicians valuable time and encourage safe and effective clinical documentation.

Avoiding and Managing Error in Interventional Radiology Practice: Tips and Tools

While there are limited data on error in interventional radiology (IR), the literature so far indicates that many errors in IR are potentially preventable. Yet, understanding the sources for error and implementing effective countermeasures can be challenging. Traditional methods for reducing error such as increased vigilance and new policies may be effective but can also contribute to an "error cycle." A hierarchy of effectiveness for patient safety interventions is outlined, and the characteristics of "high-reliability" organizations in other "high-risk" industries are examined for clues that could be implemented in IR. The evidence behind team error reduction strategies such as checklists is considered along with individual approaches such as "slowing down when you should." However, error in medicine is inevitable, and this article also seeks to outline an evidence-based approach to managing the psychological impact of being involved in medical error as a physician.

Advanced Practice Professionals and an Outpatient Clinic: Improving Longitudinal Care in an Interventional Radiology Practice

The field of interventional radiology (IR) has made tremendous advances in both scope and practice since its inception in the early 1960s. With these advances, it has solidified itself as a valuable subspecialty to the medical community and, most importantly, to the patients who receive IR care. Expanding clinical services to improve care in both the pre- and postprocedural setting is a logical step in IR maturation. The use of advanced practice professionals, in the form of physician assistants and nurse practitioners, can add value in both quality of the patient experience and exposure to other subspecialties. Furthermore, a dedicated outpatient clinic provides a centralized site to evaluate patients and communicate with referring services. These additions can be a challenging value proposition, particularly when working in a combined diagnostic radiology and IR practice, but given the benefits, these are well worth the time and monetary investments.

Catheter-Directed Therapy for Pulmonary Embolism: Patient Selection and Technical Considerations

Acute pulmonary embolism (PE) is the third most common cause of death among hospitalized patients. Treatment escalation beyond anticoagulation therapy is necessary in patients with cardiogenic shock and may be of benefit in select normotensive patients with right heart strain. Percutaneous catheter-based techniques (catheter-directed mechanical thrombectomy, clot maceration, and/or pharmacologic thrombolysis) as an alternative or adjunct to systemic thrombolysis can rapidly debulk central clot in patients with shock. Catheter-directed thrombolysis, which uses a low-dose intraclot prolonged thrombolytic infusion, is a promising but insufficiently studied therapy for patients presenting with acute intermediate-risk PE.

Post-procedural Care in Interventional Radiology: What Every Interventional Radiologist Should Know-Part II: Catheter Care and Management of Common Systemic Post-procedural Complications

Interventional radiology (IR) has evolved into a full-fledged clinical specialty with attendant comprehensive patient care responsibilities. Providing excellent and thorough clinical care is as essential to the practice of IR as achieving technical success in procedures. Basic clinical skills that every interventional radiologist should learn include routine management of percutaneously inserted drainage and vascular catheters and rapid effective management of common systemic post-procedural complications. A structured approach to post-procedural care, including routine follow-up and early identification and management of complications, facilitates efficient and thorough management with an emphasis on quality and patient safety. The aim of this second part, in conjunction with part 1, is to complete the comprehensive review of post-procedural care in patients undergoing interventional radiology procedures. We discuss common problems encountered after insertion of drainage and vascular catheters and describe effective methods of troubleshooting these problems. Commonly encountered systemic complications in IR are described, and ways for immediate identification and management of these complications are provided.