1. Patient Preparation Dr Richard Tippett IR Consultant Dorset County Hospital NHS Trust IRTB 2013

2. Objectives Understand the principles relating to: – Anticoagulation – Antibiotic prophylaxis – Sedation / Analgesia – Local anaesthesia MINIMIZE RISK! LOCAL VARIATION IRTB 2013

3. Other considerations Radiation protection – You – Allied staff members Dose reduction Patient Scatter Aseptic technique / Skin preparation IRTB 2013

4. Anticoagulation Warfarin / Antiplatelets / Heparin Elective / Urgent / Emergency Patient co-morbidities Risk of haemorrhage Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image Guided Interventions © 2012, Society of Interventional Radiology. IRTB 2013

5. Low risk cases Venous access, drain insertion, drainage tube exchange, IVC filter insertion No need for pre-procedural coagulation tests (unless on warfarin / heparin) INR<2.0 Continue aspirin / clopidogrel IRTB 2013

6. Moderate risk All angiography, most of everything else Pre-op clotting req’d, no platelet assessment INR<1.5 Platelets >50 Stop clopidogrel 5/7, continue aspirin IRTB 2013

7. High risk TIPSS, biliary, renal interventions and biopsy Check everything INR / APTTR <1.5 Plts >50 Stop aspirin / clopidogrel 5 days IRTB 2013

8. Warfarin Ideally INR < 1.5 Emergency reversal – Vitamin K: 500mcg – 2mg often gets INR to acceptable level. 10mg can cause problems with re-warfarinisation. – Prothrombin complex concentrate –Beriplex. – FFP? IRTB 2013

9. Anti-platelets Aspirin, Clopidogrel, Dipyridamole. Single agent regime- No indication to stop for most IR procedures. Dual agents- stop one (e.g. Clopidogrel) for 5/7. Patients with drug eluting stent/carotid stent. IRTB 2013

10. Antibiotic prophylaxis World wide attention on drug resistant bugs Most guidelines/ reviews extrapolate from surgical data. Some evidence specific to IR. Helpful to categorise into:- – Clean – Clean contaminated. – Dirty. Practice Guideline for Adult Antibiotic Prophylaxis during Vascular and Interventional Radiology Procedures © 2010, Society of Interventional Radiology IRTB 2013

11. Clean If the gastrointestinal (GI) tract, genitourinary (GU) tract, or respiratory tract is not entered Inflammation is not evident No break in aseptic technique. Routine diagnostic angiography. No prophylaxis required. Stent-grafts? IRTB 2013

12. Clean contaminated If the GI, biliary, or GU tract is entered Inflammation is not evident No break in aseptic technique. Nephrostomy tube placement in a patient with sterile urine. Also UAE 1gm Cef IRTB 2013

13. Dirty If it involves entering an infected purulent site such as an abscess, a clinically infected biliary or GU site, or perforated viscus. Prophylaxis is mandatory, adjunct to existing therapy. WATCH FOR SEPSIS IRTB 2013

14. When to administer? Optimal timing is within 2hrs of the procedure. If the AB is given 3 hours pre/post, the infectious complications are 5X greater. If clean, clean contaminated 1 dose lasting 6-8 hours is adequate. Contact your friendly Microbiologist. Classen DC, Evans RS. Pestotnik SL. Ct al. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Eng/J Med 1992:326:281-286 IRTB 2013

15. Sedation / Analgesia IRTB 2013

16. Sedation / Analgesia Get good at it and give it! Need to be monitored- Not by you! Need to be fasted for 6 hours (solids + Milk) 2Hrs (Clear fluids) Give Analgesia first then sedative 5-10 minutes later- Synergistic effects. PCA in complex / embolisation cases IRTB 2013

17. Fentanyl Particularly useful- Onset within 1-2 minutes. Short duration of action. Repeated doses have a longer duration. Dose 50-200 mcg then 50mcg as required. Does not accumulate in renal failure. Naloxone- 400mcg to 2mg. IRTB 2013

18. Midazolam Conscious sedation – Responds to non-painful stimuli. Maximum onset 10-15 minutes. Dose- 2mg/ 0.5-1mg in the elderly. Paradoxical excitement/aggression. Flumazenil- 200mcg over 15 secs then repeated doses of 100mcg (usually need 400- 600 mcg) IRTB 2013

19. Local anaesthesia Topical:- – Amethocaine (Amitop) better than EMLA. – Needs to be put on at least half an hour prior to procedure. Injectable – Lignocaine (Lidocaine) – Lignocaine + Adrenaline (Xylocaine) – Bupivicaine (Marcain) IRTB 2013

20. Doses Lignocaine:- – 4 mg/KG – 1% = 10mg/ml – 28 mls of 1% for 70Kg patient. Xylocaine:- – 7mls/KG – 53mls of 1% for 70 Kg patient. – Anaesthetists will give more Marcain – Max 60mls using 0.25% solution. IRTB 2013

21. Administration Use smallest needle possible for the skin. Always aspirate before injecting. Inject slowly. Ultrasound guided administration – encase the target. Overdose – give IV lipid emulsion IRTB 2013

22. Summary Understand the principles relating to: – Anticoagulation – Antibiotic prophylaxis – Sedation / Analgesia – Local anaesthesia MINIMIZE RISK! IRTB 2013