1. Biliary intervention; sedation and analgesia. Is it good enough? Dr CKL Cook Interventional Radiologist Weston General Hospital and Bristol Royal Infirmary No conflicts of interest

2. Overview Background of patients and pathology, and imaging The procedure The risks Survey of IR across SW UK Conclusions

3. Overview Background of patients and pathology, and imaging The procedure The risks Survey of IR across SW UK Conclusions

4. Biliary intervention; patients/ pathology Biliary obstruction; carcinoma pancreas, cholangiocarcinoma, Lymph nodes/ adjacent tumours, hepatic metastases, benign causes. Elderly, chronic ill-health, near end of life

6. Presentation Painless jaundice Obstructive; pale stool, dark urine Weight loss Abdominal or back pain Other indicators of primary or secondary disease

7. Investigations Ultrasound CT for evaluation, and full staging Magnetic resonance cholangiography (MRCP)

9. Investigations Ultrasound CT for evaluation, and full staging Magnetic resonance cholangiography (MRCP)

11. Investigations Ultrasound CT for evaluation, and full staging Magnetic resonance cholangiography (MRCP)

15. Overview Background of patients and pathology, and imaging The procedure The risks Survey of IR across SW UK Conclusions

16. Intervention for biliary obstruction MDT; Surgical, palliative, or best supportive care Planning for intervention ERCP- Endoscopic retrograde cholangio- pancreatography and stent. 1st line PTC- percutaneous transhepatic cholangiography/ drainage/ stent. 2 nd line, unless known duodenal compression or proximal lesions.

18. Percutaneous biliary intervention Percutaneous drain or stent U/S and flouroscopic guidance; in Radiology Dept Hydration, antibiotics, clotting, preliminary U/S to confirm extent of duct dilation WHO/ RCR pre IR checklist

21. Metallic biliary stent Wall stent (Boston Sci) Zilver (Cook Medical)

22. Overview Background of patients and pathology, and imaging The procedure The risks Survey of IR across SW UK Conclusions

23. High Risk Percutaneous biliary interventions are high risk procedures, with data suggesting immediate mortality of between 0.6 and 5.6% (1-4) The UK Percutaneous Biliary Drainage Audit (2012) showed mortality at 30 days in the region of 19%*. *British Society of Interventional Radiology: Biliary Drainage and Stenting Registry (BDSR) Cardiovasc Intervent Radiol (2012) 35:127-138

24. High risk stratification* Immediate Albumen less than 30 Ascities WCC greater than 14, CRP greater than 50 Hb less than 11 Early Urea greater than 12 Bilirubin greater than 300, and ALT greater than 150. * Eur Radiol (2011) 21:1948-1955

25. Summary Patients, pathology, imaging MDT planning Types of intervention High Risk

26. Overview Background of patients and pathology, and imaging The procedure The risks Survey of IR across SW UK Conclusions

27. Regional Survey Regional survey of Interventional Radiologists across the South West of the United Kingdom Approx 60 interventional Radiologists, and 40 IR nurses Southampton – Oxford – Bristol – Plymouth – Cardiff CIRSE; Cardiovascular and Interventional Radiology Society Europe, Lisbon 2015

28. Patient pain % patients

29. 2. The % of patients that appear to experience MORE than moderate pain, or move during procedure

30. Overall level of analgesia and sedation % Respondents

31. Comments/ Conclusions Although a small number of both IR nurses (28%) and interventionalists (16%) feel that an anaesthetist is unnecessary for these procedures, 57% IR nurses, and 64% of interventionalists felt that patients experience moderate to severe pain, and 72% of nurses felt that an anaesthetist would improve the patient experience. 37% of interventionalists stated they never had an anaesthetist but would like one, and more than 50% said they did not due to a difficulty to organise at short notice (and small case load). 50 % of IR teams have never had formal training in sedation. Only 5% of teams routinely have anaesthetic support.

32. Qualitative responses IR nurses… Procedure often poorly tolerated PTC patients deserve and require better pain relief We are aware of occasions when a patient will be in a lot of pain Radiologists… Difficult to predict Highly variable Sedation and analgesia is somewhere between poor and satisfactory I strongly believe anaesthetic cover should be the norm Not normally a problem Pain can be severe, and difficult to control

33. Anaesthetic role Pre-intervention clinical review Maximise pre-operative state; renal, hydration, cardiac, infective Sedation and analgesia Patient relaxed, reassured, pain free, and still Post operative care

34. Overview Background of patients and pathology, and imaging The procedure The risks Survey of IR across SW UK Conclusions

35. Benefits; (based on medical rationale and quality of care) Second opinion for IR team Maximise pre-operative state Analgesia – per and post operative Properly trained in sedating, and monitoring analgesic levels Problems; (issues of management and logistical limitations) Short notice Small and un-predictable caseload number

36. Biliary intervention; sedation and analgesia. Is it good enough? Dr CKL Cook Interventional Radiologist

37. Biliary intervention; sedation and analgesia. Is it good enough? No, not without an anaesthetist Dr CKL Cook Interventional Radiologist

38. References 1. Mueller PR, van stonnenberg E, Ferrucci JT Jr (1982) Percutaneous biliary drainage: technical and catheter-related problems in 200 procedures. AJR Am J Roentgenol 138:17-23 2. Yee ACM Ho CS (1987) Complications of percutaneous biliary drainage: benign vs malignant diseases. AJR Am J Roentgenol 148:1207-1209 3. Clark RA, Mitchell SE, Colley DP, Alexander E (1981) Percutaneous catheter biliary decompression. AJR Am J Roentgenol 137:503-509 4. Carrasco CH, Zornoza J, Bechtel WJ (1984) Malignant biliary obstruction: complications of percutaneous biliary drainage. Radiology 152:343-346 5. Uberoi R, Das N, Moss J, Robertson I. British Society of Interventional Radiology: Biliary Drainage and Stenting Registry (BDSR) Cardiovasc Intervent Radiol (2012) 35:127-138 6. Tapping CR, Byass OR, Cast JEI Percutaneous transhepatic biliary drainage (PTBD) with or without stent complications, re-stent rate and a new risk stratification score. Eur Radiol (2011) 21:1948-1955