Transcript SAR London 2016 1 1 - Society of Anaesthetists in Radiology

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
Overview
• Background of patients and pathology, and imaging
• The procedure
• The risks
• Survey of IR across SW UK
• Conclusions
Overview
• Background of patients and pathology, and imaging
• The procedure
• The risks
• Survey of IR across SW UK
• Conclusions
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
Presentation
• Painless jaundice
• Obstructive; pale stool, dark urine
• Weight loss
• Abdominal or back pain
• Other indicators of primary or secondary disease
Investigations
• Ultrasound
• CT for evaluation, and full staging
• Magnetic resonance cholangiography (MRCP)
Investigations
• Ultrasound
• CT for evaluation, and full staging
• Magnetic resonance cholangiography (MRCP)
Investigations
• Ultrasound
• CT for evaluation, and full staging
• Magnetic resonance cholangiography (MRCP)
Overview
• Background of patients and pathology, and imaging
• The procedure
• The risks
• Survey of IR across SW UK
• Conclusions
Intervention for biliary obstruction
• MDT; Surgical, palliative, or best supportive care
• Planning for intervention
• ERCP- Endoscopic retrograde cholangiopancreatography and stent. 1st line
• PTC- percutaneous transhepatic cholangiography/
drainage/ stent. 2nd line, unless known duodenal compression or
proximal lesions.
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
Metallic biliary stent
• Wall stent (Boston Sci)
• Zilver (Cook Medical)
Overview
• Background of patients and pathology, and imaging
• The procedure
• The risks
• Survey of IR across SW UK
• Conclusions
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
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
Summary
• Patients, pathology, imaging
• MDT planning
• Types of intervention
• High Risk
Overview
• Background of patients and pathology, and imaging
• The procedure
• The risks
• Survey of IR across SW UK
• Conclusions
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
%
patients
Patient pain
2.
The % of patients that appear to experience MORE
than moderate pain, or move during procedure
Overall level of analgesia and sedation
%
Respondents
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.
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
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
Overview
• Background of patients and pathology, and imaging
• The procedure
• The risks
• Survey of IR across SW UK
• Conclusions
Conclusions
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
Biliary intervention; sedation and analgesia. Is it good
enough?
Dr CKL Cook
Interventional Radiologist
Biliary intervention; sedation and analgesia. Is it good
enough?
No, not without an anaesthetist
Dr CKL Cook
Interventional Radiologist
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