Klemens

H. Barth,

MD

#{149} Alan

Patient Care A Perspective’

W

the separation diagnostic

ITH

into

H. Matsumoto,

in Interventional

of radiology radiology and

radiation in the 1970s,

therapy, which took place United States during the early most radiologists gave up their

direct become

patient care diagnostic

tants.

In effect,

mote rectly

from dealing except for

ing

certain For

responsibilities imaging consul-

radiologists

diagnostic

didur-

procedures

angiographers,

diagnostic

re-

patients contacts the

catheter

use

(1). of the

as a therapeutic

end,

establishing

trust

between

sequently, the gist is required the

gist

into

risks

rect

patient

care.

Those

who

significance as life-saving

the tact

the

patient’s

of these

patient. is better

of

well-be-

can

terms: and

Radiology

‘From Georgetown Reservoir (K.H.B.), Blake

1991;

procedures departmental

#{149} State-of-the-art

agement

LW.

Interventional radiologists,

#{149} Raman-

the

inand

time

for an unexchange with

Therefore, established

be done

patient conin advance.

during

Diet

an office

Adjustment and

vascular

changes,

catheter

or to the

inpatients

for

are

8-12

allowed

procedure.

receive

interventional and simple

solid

hours,

until

but

2 hours

In addition,

intravenous

178:11-17

Department of Radiology, University Medical Center, 3800 Rd, NW, Washington, DC 200078 and the Department of Radiology,

non-

food

Hospital,

Bradenton,

1991

Fla

June

(A.H.M.).

8. Ad-

the

morning

and continued If the patient the procedure,

ing insulin dose is given (10). Preprocedure consultation should be obtamed for patients with poorly controlled

diabetes.

Diuretics are usually withheld the day of the procedure in order minimize dehydration. Anticoagulation with warfarin (Coumadin)

is withheld

for

on to

several

days prior to a procedure patient’s prothrombin

to allow the time to return

to normal.

anticoagula-

If required,

tion can be maintained with intravenously administered heparin up to 4 hours before the procedure. (Further details are provided in Bleeding Complications.) of Renal

Function

Patients with abnormal renal function (serum creatinine level greater than 1.5 mg/dL [130 mol/L]), and those with dehydration, multiple myeloma, and diabetes are generally at increased

risk

for

renal

failure following intravascular administration of contrast material (1 1). Use of nonionic contrast agents has so far not been shown to reduce that risk (12,13). However, the overall in-

primost

prospective

hydra-

Adjustment diabetics have insulin dose reIntravenous adminisof fluids containing 5% dex-

(14).

study

In addition

on 220 patients to hydration,

pa-

tients at increased risk for nephrotoxicity receive mannitol (25 g in 250 mL

of normal

2-hour

period

saline

solution)

immediately

over

after

a

the

procedure (15). Follow-up serum creatinine levels are measured. In any questionable case, consultation with a nephrologist should be considered.

Insulin-dependent their preprocedural duced by 50%.

tration

of the

during the is able to eat the remain-

cidence of contrast material-induced nephropathy is lower than previously believed, according to a recent

clear

the

Medication

is initiated

procedure procedure. following

considered

PREPARATION

For diagnostic vascular procedures

trose

Assessment

tion overnight. For nonvascular interventional procedures, in which hydration is less important, it is best to withhold all oral intake, except medications, for 8-12 hours.

reviews

Received May 15, 1990; accepted dress reprint requests to K.H.B. RSNA,

benefits

PROCEDURE

liquids diology

also

visit or by means of an extensive telephone dialogue and advance mailing of printed information (2,3).

is withheld

Index

but

is essential.

This

embolization for massive bleeding, salvage of a limb by means of regional thrombolysis and transluminal angioplasty, and effective palliation with biliary, urinary, and abscess

drainage-to ing.

in-

radioloonly

not

procedure

sis, leaving little rushed information

to admit patients (2-4). Others formed teams with established clinical specialists, such as vascular surgeons (5,6), while many were reluctant to expand their responsibilities beyond performing procedures (7). Interventional radiologists should

the

the

Many interventional procedures are currently performed on outpatients or on a “same-day-admit” ba-

reacted

quickly to this need started outpatient clinics and obtained privileges

not underestimate their procedures-such

of

and

and risks of alternatives, surgery. A fundamental

knowledge

in di-

patient

interventional to discuss

proposed

benefits cluding

involved

an atmosphere the

terventional radiologist is essential. The patient needs to understand clearly what is to be done and must be offered a choice of alternative treatments or no treatment (9). Con-

tool became more commonplace toward the end of the 1970s, again transforming the diagnostic radiolo-

a “therapist”

Radiology:

Informed consent is a prerequisite for any diagnostic or therapeutic interventional procedure (8). To this

to

were

with limited

MD

Abbreviation:

ECG

=

electrocardiogram.

Use

of Prophylactic The

Antibiotics

principle

laxis

of antibiotic

is to prevent

sterile

tissue

bacterial

secondary

seeding

prior

procedure et a! (18)

are not recently

of

PROCEDURES

prophylactic endocarditis

to bacter-

emia, which may be associated an invasive procedure (Figure) 19). Such prophylaxis will not vent bacteremia or endotoxemia Recommendations for antibiotic

phylaxis

VASCULAR Patients

prophy-

with (16pre(20). pro-

pertainfrg

and prosthetic to sterile prcwedures.

Exception:

Organ (liver,

ablation kidney):

hours

(start

well defined. Spies attempted to estab-

BILIARY

AND

URINARY

Prophylactic

DRAINAGE are administered and urinary

antibiotics

ences

ing unimpaired drainage established tracts do not

ages

in opinions exist about the efficacy of prophylaxis and what medical situations require its use (17,2124).

Patients undergoing lar procedures do not

sterile require

vascupro-

prophylaxis

prior

organ or tumor recommended,

to embolization ablation to prevent

of necrotic

regularly

preparation

include

care of patients chemoembolization. For biliary

procedures,

and

equally critical. ic prophylaxis 1 hour before

in

is

In addition, is administered these procedures

measure to prevent not found that the

tion

of prophylactic

infection. administra-

We

results

af-

of closed

flu-

id collections. Eventually, all chronic percutaneous and indwelling drainage catheters become colonized with bacteria (20), but clinical infection is not likely to develop in patients who are not immunocompromised unless drainage becomes Postprocedure

clinical

obstructed Care).

evidence

percutaneous

(29) Patients

drainage

or who receive

ple antibiotics, trum of expected

THE

prior

which cover pathogens

CONTROL AND

OF PAIN

Prophylactic

one

dures

are

However,

to

are multi-

the spec(18,24).

ANXIETY

radiologic

less

appreciated 12

invasive

this

#{149} Radiology

advantage

by

a patient

biliary

Catheter

checks

catheter exchanges prophylaxis unless

procedures:

2 g intravenously,

dur-

through the

Inpatients

receive

or ampicfflin,

cefopera-

2 g intravenously,

gentamicin, 1 .5 mg/kg intravenously. Outpatients receive a dose of ceftrlaxone sodium, 2 g intravenously. A bile spec!for culture and sensitivity is obtained as soon as the bile are

entered.

proce-

than

should

suffering

not

be

for

consider

interventional

the

provided

radiologic

effective by

ventional radiologist’s the procedure (32).

the

visit

inter-

lar medications, and associated medical problems (pulmonary, cardiac, liver, or renal disease) (31). Most interventional radiologic procedures can be performed with local anesthesia supplemented by an intravenously administered combination of an narcotic

(33).

The

and

a benzodiazepine

intravenous

be given

doses

in small

monitoring, particularly of older patients, is not possible in general care units and during transfer to the laboratory. We prefer to perform baseline assessment of vital signs in the laboratory before sedation. We then administer our medications intrave-

supplemental

sedation

nously while the patient is monitored by means of electrocardiography (ECG), oximetry, and blood

contrast

not

“on

the

ever, tient’s

and

give floor,”

recording.

one should age, weight,

previous

premedica-

since

Standard

regimens

pain,

routine

are

adequate

consider degree

response

Diazepam

used

but

Lorazepam

action

and

how-

the paof anxiety

to simi-

tating two.

has

a short does or

is also on Dose

delayed water

injection frequencies

amnesia

been

widely

long

acting.

best

amnesic

but

long sedative a rapid onset

half-life

to diazepam

sedation and

and has

is the

has a comparatively fect. Midazolam

titrated

(Table 1). are useful for

is relatively

Midazolam pres-

intravenous available;

(34,35).

should

increments

effect

do

to penicil-

procedures.

opioid

before

allergic

1 g intravenously,

to the desired Benzodiazepines

We

dosing

surgery. may

antibiotics

“anxiolysis”

sure Interventional

for

from pain and anxiety during such a procedure. Therefore, the interventional radiologist must be familiar with the use of sedatives, analgesics, and antiemetics (30,31). Before resorting to routine “on-call” medications,

tions

(see also with

of infection

immunocompromised

infected.

3. AlternatIve antibiotic prophylaxis: Patients lins and cephalosporins receive vancomycin, and gentamicin, 1 .5 mg/kg Intravenously.

antibiotwithin (Fig-

antibiotics

culture

as

and routine require such

drainage

technique

tive have

the

ducts

hepatic

urinary

identified

hour before and drain-

2. Prophylazl. for urinary tract procedures: Ampicfflin, 2 g Intravenously, and gentamlcin, 1.5 mg/kg intravenously. Patients with limited renal function may receive cefoperazone, 2 g intravenously. Preferably, urinalysis and urine culture have been performed before the procedure; If not, a urine culture is performed during the procedure.

ure). Once decompression of an uninfected system is established, antibiotics are discontinued after 48 hours. Decompression of the obstructed fluid collection is the single most effec-

fects

men

postprocedure

undergoing

sterile

single

(25-28).

antibiotics

and

not

PROCEDURES within the tract procedures

is immunocompromised.

and

for

material

fluids

Prophylazi. zone sodium,

1.

is strongly secondary

billary

of other

patient

phylactic antibiotics even when they have abnormal heart valves or valve prostheses (18). However, antibiotic

the

12

to an interventional

all percutaneous

We

procedures those with Implants. Strktly

(spleen, kidney) or tumor embollzatlon Cefotetan, 2 g, Intravenously, every within 1 hour before the procedure).

lish rational guidelines based on data from the surgery literature. Differ-

infection

do not require a history of bacterial adhere to the rules

undergoing sterile vascular antibiotics, Including

(36)

and lead

not

in

lorazepam. to recurrent

drowsiness soluble

(37)

and

than

the

less

irri-

other

should

between 5 and 10 minutes oversedation. No definite

efof

be

kept

to prevent antagonist January

1991

Table 1 Sedatives,

Analgesi

cs, and

Antic metics

for Interventio

nal Radi ologic

Procedures

Intravenous

Total

Onset

Duration

Dose

Dose

(mm)

(h)

2-3

6-24

Delayed larly!

10-20

Drug

Comments

Benzodiazepines Diazepam

1-5

Lorazepam

0.5-2.0

mg

2-4

Mida.zolam

0.5-2.0

mg

0.035-0.15

Narcotic analgesics Morphine

mg

1-5 mg

Meperidine

12.5-25

Fentanyl

15-75

Naloxone

10-25

(narcotic

mg

mg

mg

0.5-1

g

0.4-0.8

1-3

mg

mg/kg mg/kg

Best

1-2

Good

5-10

3-4

May cause

2-4

duct pressure Less effect on common

3-5

Dose is repeated

antagonist)

6-16

gig/kg

as

amnesic

from

2

mg/kg

0.05-0.2

sedation

Minimal

2

0.3-0.5

For narcotic

10 mg 2.5-10

Promethazine

mg

12.5-25

Droperidol

are

mg

0.625-1.25 mg

Note-All these medications compatible solutions. * All can cause extrapyramidal

0.5-1 mg/kg 10 mg

1-3 10-20

1-2 4-6

Stimulates Use a lower

25 mg

10-20

4-6

Central

evaluated analgesics

decrease carbon

Higher doses tive effect

should

dioxide,

1) can

response stimulate

to nausea

and

vomiting, and decrease intestinal motility. Use of narcotics with anxiolytics, such as the benzodiazepines or antiemetic agents, can produce a synergistic effect in pain control (30,39). Morphine, meperidine, and fentanyl are the narcotics most frequently used most

parenterally.

Fentanyl

for sedaslowly

10-15

when

given

4-6

has

the

certain

procedures,

such

as

embolization compression. antiemetics

of tumors or biliary deGiven prophylactically, can minimize nausea and vomiting. Their effects are also synergistic with narcotics in reducing the perception of pain (30,39). Most of these agents have some blocking effect of dopaminergic renergic receptors;

and therefore,

can cause extrapyramidal and hypotension.

alpha-adthey

lasts

quires several of action. The be prolonged

Volume

178

1-2

symptoms

every

20 minutes

upper

nervous

lasts

4-10

are

rarely

minutes

but

before

duration of action when epinephrine #{149} Number

1

associated

of re-

onset can is

with

true allergic reactions. Most adverse reactions are related to overdose, epinephrine effect, or vasovagal reaction. When a patient has a history of a true allergy to either of these drugs, an ester anesthetic such as tetracaine or procaine may be substituted. The converse is also true, since there does

cal

anesthetic

local

provided

(40).

by a pleural

Epidural

can

block

fluid

patients patients dural

own

also

control during cholangioplasty, nephrolithotripsy

anesthesia

radiologists

a ce-

interfor

tract

effects additive with extravasation can cause

may cause dysphoria; packet

motility

patients

system depressant benzodiazepines;

insert

potent

for specific

antiemetic

rates

at low

of administration

be

is rarely

tional radiologist should to enlist help from other

he or she ideally Still, the interventional radiologist must be familiar with methods to minimize complications and propriately

should

blood

be

able

pressure

to react

recording,

oximetry, and ECG (30). should be present during dures. Bleeding

re-

radio-

ap-

pulse

A nurse all proce-

tin time, reasonable

RISKS

fore

are as-

Complications

Disorders of bleeding are usually screened for by measurement of prothrombin

time,

and

interventional

not hesitate medical spe-

celerated by mm K orally, intramuscularly,

thromboplas-

count (44). to screening

A be-

(nonvascular)

procedures has been posed by Silverman Reversal

or

partial

platelet approach

of an

bin time secondary ciency or warfarin

In treating

with multisystem disease who develop a periprocecomplication, the interven-

whom

bili-

clinical responsibilmust remain cognizant

limitations.

with

as a team.

works

matic

drainages can

quired for an interventional logic procedure in adults.

of their

be

(41),

(42), or an particularly

anesthesia

helpful for pain ary decompression, or percutaneous General

reactivity “ester” lo-

anesthesia

liac ganglion block costal nerve block, biliary or abdominal

(30).

cross and

groups

Extended

suming broader ities, yet they

Bupiva-

hours

manufacturer’s

gastrointestinal

for elderly

dose

to emergency situations. The radiologist and laboratory personnel should be certified annually in cardiopulmonary resuscitation. Preferably, the interventional radio!ogist and the interventional radiology nurse are also certified biannually in advanced cardiac life support. Standards for these certifications have been set by national consensus and are updated periodically (43). To facilitate recognition in the laboratory of a developing complication, all patients are monitored with auto-

and

Interventional

hours.

See

MANAGEMENT OF AND COMPLICATIONS

Local anesthesia is used in the form of either lidocaine or bupivacaine. Lidocaine has a rapid onset action

to repeat

thetics

(33).

caine

may need

cialists

useful

and

pressure

added, but tachycardia can result from the systemic absorption of epinephrine. Bupivacaine and lidocaine can be combined for rapid onset and longer action. Both are amide anes-

not appear to be any between the “amide”

action

bile

effects

overdose;

Higher doses doses

intravenously.

rapid onset of action and the shortest half-life. Naloxone, a pure narcotic antagonist, can be used to treat an overdose. Since the effect of naloxone is short-lived, recurrence of the narcotic effect should be watched for (31). Antiemetic agents (Table 1) may be for

duct

a rise in common

effects.

a!drugs

(38). (Table

respiratory

be administered

side

for these medications, a number of different

being Narcotic

and/or

bile

cardiovascular

narcotics and tissue necrosis

exists though

release

needed

Antiemetics* Metaclopramide Prochiorperazine

and

intramuscu-

agent

histamine

0.5-1

not give

do

agent

amnesic

2

metabolites;

recently proet al (45).

abnormal

prothrom-

to vitamin K defitherapy can be ac-

administration of vitasubcutaneously, or intravenously

(Table 2). Therapeutic effects occur 6-8 hours after intravenous adminisRadiology

#{149} 13

Table

2 Management

of Common

Coagulation

Clotting

Parameter Prothrombin

Value

time

coagulation

Deficiencies

Normal

(extrinsic

of value

control

of Abnormal

thromboplastin

(intrinsic

Within

time

coagulation

sys-

control

Treatment

Vitamin K, 10-15 mg intramuscularly ously every 8 h for three doses, ma, 10-20 mL/kg

Liver disease Vitamin K deficiency

Partial

Values

Warfarin

3 sec

Within

system)

Causes

Fresh (parenteral

tion, biliary obstruction, antibiotics) Coagulation (disseminated coagulation, thrombolytic Congenital (hemophilia) Warfarin

6 sec of value

nutri-

frozen

Vitamin

malabsorption,

K,

plasma, 10-15

every

ously

10-20

mg

or subcutane-

or fresh

frozen

plas-

mL/kg

intramuscularly

8 h for three

or subcutane-

doses,

or fresh

frozen

plas-

ma, 3-4 U intravascular

Treat

initiating

cause

therapy) Consult

hematologist

Vitamin

K, 10-15

ously

tem)

every

mg

intramuscularly

8 h for

three

or subcutane-

doses,

or

fresh

plas-

frozen

malO-2OmL/kg Heparin

Wait

4-6

h after

mg per 100 Bleeding

time

Less

than

Lupus anticoagulant Quantitative: platelet

8 mm

than

No treatment count

less

stopping U of heparin)

heparin

or give

protamine

intravenously,

very

(1

slowly

necessary

Platelet

transfusion

(10 units)

Uremia:

hemodialysis,

50,000/mm3

Qualitative:

uremia, antiplatelet, antiinflammatory

steroidal

and

non-

drugs

kilogram),

Congenital:

Von Willebrand

disease,

Consult

cryoprecipitate

and/or

Drugs: stop verse)

DDAVP*,

medications

0.4

(0.1-0.2

bag

over

30 mm

g/kg

(requires

days

to weeks

per

to re-

hematologist

thromboasthenia *

1-deamino-(8-D-arginine)-vasporessin.

Table

3

Emergencies

of Cardiovascular

Treament

Dose

Symptoms

Medication

Symptomatic

bra-

Atropine

Dose 0.5-1.0

mg

Maximum

Frequency

IV

5-mm

Dosage

intervals

Comments

2 mg IV

Doses

dycardia

smaller

maker, Ventricular

Lidocaine

bolus

1 mg/kg

IV

repeat

tachyarrythmia

0.5 mg/kg

every

Supraventricular

Verapamil

0.1 mg/kg

Nitroglycerin

0.3-0.4

tachycardia

N slowly

(maximum

of

0.15

10

IV

8-10 mm

mg/kg

30 mm

mg) Angina

IV slowly after

3 mg/kg dose

total

Once

bolus

sublin-

Hypertension

Nifedipine

10-20

Nitroglycerin ointment

1-2

mg

orally

inches

first

Every

5 mm

Three

10-30

mm

Titrate

to effect

Titrate

to effect

3-4

h

tablets

2% Hypotension

1 mg

Dopammne

2-5

IV

per

Mg/kg

(via

nous

dose

test

central

mm ye-

5 mg

IV as needed

Titrate sure

dose

to pres-

None

20 ig/kg/min

IV

12-36

hours

after

some of the transfused factors is limited. An isolated abnormal

subcuta-

neous or intramuscular application; intravenous administration carries the risk of an anaphylactic reaction. Transfusion of fresh frozen plasma will immediately restore deficiencies coagulation either vitamin

disease,

Procedures

soon after administered, 14

#{149} Radiology

mg/ cafl

associat-

necrosis

intravenous.

-

cy, liver

continu-

at 2-4 occurs,

Above 10 ig/kg/min, significant renal, peripheral, and mesenteric vasoconstriction occurs; extravasation from peripheral venous access can cause

effect

access)

skin

of various suit from

a

bradycardia

is controlled

For treatment of hypertension ed with pheochromocytoma

lenge

or

for refractory

arrhythmia

cause

much

Phentolamine

(unresponsive) to fluid chat-

Note.-IV

may

and lead to demand pace-

code and defibrillate Use is contraindicated with N beta blockers; can be used with patients receiving digitalis If pain persists, obtain 12-lead electrocardiogram and consult cardiologist; treat any precipitating cause Can cause precipitous fall of blood pressure; effect lasts 2-4 h; if refractory, consider nitroprusside Requires 20-30 mm to see effect; can be wiped off if blood pressure drops too

20 mg IV

dose mg

0.5 mg

bradycardia fibrillation;

ous infusion of lidocaine mm; if circulatory arrest

gually

tration

than

paradoxical ventricular

or warfarin

should

the

factors that K deficien-

fresh since

be

re-

therapy.

performed

frozen plasma is the half-life of

coagulation partial

by intravenous protamine slowly

thromboplastin time is usually related to heparin infusion. Heparin is metabolized by the liver and excreted by the kidneys. The half-life of heparin is dose dependent (46). For most heparin doses used during vascular interventions (47), the half-life averages 30-60 minutes. The heparin

a hypotensive

effect

the

can

be reversed

immediately

tamine

the

reaction.

acts

dose

Protamine lactoid

administration

of

sulfate, which is injected at a rate of 2 mg/mm to avoid as an

Excess

should

be titrated

may reaction,

also cause especially

dependent diabetics (48). its administration should monitored.

heparin

We

prefer

effect

pro-

anticoagulant,

so

(Table

3).

an anaphyin insulin-

Therefore, be closely

to wait

is completed, January

until

by 1991

Table

4

of A naphylactoid

Treatment Clinical Symptom

Reactions

Medication

Dose Frequency

Dose

Comments

Urticaria

Diphenhydramine

25-50

mg

IV

May

repeat

once

25-50 mg As above

IM

May repeat As above

once

Angioneurotic edema

Hydroxyzmne Diphenhydrammne or hydroxyzmne Epinephrine

0.3-0.5 mL SC or IM, 1:1,000 dilution

Repeat mm

Epinephrine

0.3-0.5

Aminophyliine

1:1,000 6 mg/kg min,IV

Epmnephrine

0.3-0.5

Bronchospasm

Laryngospasm

mL

mL

1:1,000 Note.-IM

intramuscular,

=

IV

intravenous,

SC

SC

or

IM,

dilution over 20 SC or dilution

IM,

Treat

if symptomatic

or progressive

For symptomatic

every 10 as needed

subcutaneous swelling

As above

May

in patients

Maintenance, mg/kg/hIV

ease If suboptimal nephrmne

0.6

As above

For

induce

severe normal

angina

response reaction, give saline IV slowly;

Platelet abnormalities can be quantitative or qualitative, and both lead to a prolonged bleeding time. Platelet counts above 100,000/mm3 (100 X

encountered emic heart

been tive

and

monary

109/L)

time

less

a minute

than

tional

the partial thromboplascan be performed in

procedure

in the

are usually

terventional

interven-

room.

satisfactory

procedures.

for in-

Counts

low 50,000/mm3 (50 X 109/L) prophylactic platelet transfusion The decision counts are 100,000/mm3

be-

require (49).

to transfuse when between 50,000 and (50 and 100 X 109/L)

depends on the nature of the procedure and how well the platelets are functioning. In general, 10 units transfused platelets will increase platelet count by 50,000-100,000/

mm3 (50-100 of transfused tween

hours

X 109/L). platelets and

days,

so platelet

are usually prior to the procedure. The qualitative platelet

tion

associated

improved bleeding lowing

with

performed dysfunc-

uremia

can

be

with hemodialysis. If the time is still prolonged foldialysis, transfusion of cryo-

precipitate and/or (8-D-arginine)-vasopressin

of 1-deaminowill

fur-

ther improve platelet function (49) (Table 2). Aspirin (acetylsalicylic acid) is presently widely used as a plateletsuppressant drug to reduce thromboembolic complications of atherosclerosis. Dosages vary between 80 and over there

1,000 mg/d (50-52). is good theoretical

Although reason to

use the low doses (75-175 mg/d) (53,54), no firm dosage guidelines have been established. Antiplatelet drugs, such as aspirin, usually cause a 1-2-minute prolongation of the bleeding time, but the antiplatelet effects of these agents can be magnified by any other abnormality in hemostasis (55). Restoration of

Volume

178

#{149} Number

1

clearly defined, value of a screening

is controversial

other

bleeding

the predicbleeding

(57,58). parameters

If all are

nor-

mal, we perform interventional procedures despite recent ingestion of antiplatelet agents. For elective cases that are associated with a significant risk of bleeding, such as percutaneous nephrolithotripsy, we will withhold antiplatelet agents for 1-2 weeks

prior

to the

scheduled

pro-

cedure. Despite

The half-life varies be-

transfusions just

of the

0.5

compromise

with

coronary

artery

symptoms

mL of 1:1,000 call code team

dis-

after in

epi-

10 mL

of

subcutaneous.

aspirin admin3-4 days and days (56). The a surgical or after ingesagent has not

this

or airway

or recurrent

platelet function after istration takes at least may take as long as 10 risk of bleeding during interventional procedure tion of an antiplatelet

monitoring tin time;

angioedema

For mucocutaneous

normal

coagulation,

pa-

tients with hypertension, obesity, and calcific atherosclerosis are at increased risk for procedure-related bleeding. If symptomatic bleeding occurs and availability of blood products has not been prearranged, the patient’s blood should be typed and cross-matched immediately. Meanwhile, normal saline or lactated Ringer

solution

rapidly

to maintain

should

while

control

site

is attempted.

be infused

blood

pressure

active

bleeding

of the

pine should be administered cautiously in patients with ischemic heart disease (59). Occasionally tachyarrhythmias in patients disease and

Arrhythmias are usually selfsustained supraventricular or ventricular tachycardia can occur. If symptomatic tachyarrhythmias occur, a cardiologist should be consulted immediately, or if the

arrhythmia

A variety cations

can

of cardiovascular arise

during

complian

interven-

tional procedure (Table 3). Perhaps the one most frequently encountered is a vasovagal reaction resulting in brachycardia. This may be managed by means of conservative measures (administration of oxygen, intravenous administration of fluids, cough induction); however, if chest pain, dyspnea, hypotention, light-headedness, or ventricular ectopy occur (symptomatic bradycardia), atropine should be given intravenously. Atro-

is associated

with

hemodynamic compromise, a code team should be called. If there is a delay in response for assistance, the interventional radiologist should be ready to initiate emergency resuscitation including defibrillation and intravenous administration of epinephrine and lidocaine according to the principles of advanced cardiac life support (43). Pulmonary

angiography

can

also

induce cardiac conduction abnormalities, especially a transient right bundie branch block. Therefore, the patient’s ECG should be reviewed prior to the procedure; if a left bundle branch block or a trifascicular block exists, complete heart block can result. A prophylactic pacemaker may under The

Complications

are

ischpul-

arteriography. in the latter setting limited, but at times

be placed

Cardiovascular

with during

before

such stress

a study

vascular

procedure

angina

in a patient

coronary

can

artery

usually

be

is performed

conditions (60). of any interventional with disease.

relieved

or

precipitate

underlying Angina

with

can

sublingual

nitroglycerine, but if it is persistent, a 12-lead ECG should be obtained and a cardiologist consulted. Hypertension before or during a procedure is not infrequently aggravated

by

anxiety,

which again of adequate If the

sure

patient’s

rises

pain,

stresses sedation systolic

to more

or both,

the importance and pain relief. than

blood

pres-

180 mm Radiology

Hg or #{149} 15

the

diastolic

100 mm duction

pressure

to more

Hg, moderate is advisable.

needed

than

tered nifedipine is the preferred treatment; it must be swallowed to be absorbed (61). The capsule can be pierced for more rapid effect. A re-

sponse is usually seen within minutes (Table 3). In the setting of symptomatic pertension

cardiac

cardiologist be consulted

or a nephrologist for definitive

In patients

with

ma,

phentolamine

ately

available

crisis

develop

must

should (Table

and

a

this

immedi-

can

responds

de-

artery

well

Hypotension

to fluid

unresponsive

be as-

mm

Hg

sedative

and

medium

(63).

rotic

to fluid

and

Acute vascular

febrile reactions procedures are

often

related

to contamination

of contrast agents or catheters with pyrogens. Since the reaction is selflimited, only supportive measures are required. Febrile reactions associated with embolization procedures are more protracted and are related to infarction and release of endoge-

nous

pyrogens.

Again,

supportive

measures are undertaken with antipyretics, antiemetics, and narcotic analgesics (Table 1). If spiking fevers continue, an infectious cause should be sought (25-28). Most episodes of procedure-related bacteremia or endotoxemia and sepsis occur during or after nonvascular interventional procedures such as biliary or abscess drainages or percutaneous nephrostomies for pyonephrosis. The risk can be reduced by avoiding overdisten-

16

#{149} Radiology

do

require

have

is

and

If problems

clinical

occur

cy or if the

but

if rede-

airway

condition

within

staff

radiologist

to include

them

about

their

in the

rounds as an important teaching pect of interventional radiology. For outpatient follow-ups, an

fice

or clinic

should and

unrushed

patient.

the and

ad-

exchange

is

AS

CLINICIAN,

AND

FUTURE

effecalterna(64).

With

this

commit-

ment

to patient

essential

progression the

the

to care

For fellows ology, patient must become training

it is

generation

radiologists

or acquires

necessary

Therefore,

present

of interventional

sumes

comes

care.

that

ra-

for

re-

clinical

skills

these

patients.

in interventional radiworkup and follow-up an integral part of

to complement

experience

gained

or surgical

internship.

the

during

initial

a medical Such

training

in interventional radiology including clinical and procedure skills may well require 2 years following a diagnostic radiology residency. Commitment to patient care will be the best guarantee for the continued existence of interventional radiology among other clinical specialties.

asof-

be maintained

in

environ-

Acknowledgments:

ment (2). Location inside the angiographic suite is not desirable. Access should be direct and not through in-

Scott,

PhD,

patient

Marilyn

Radiology

INTERVENTIONAL

Over the years, interventional diology has developed many tive, less-invasive treatment tives to conventional surgery

and

areas.

open

Catheter

a of

performed when fever abates. We perform angioplasty follow-up at 1 month, 3 months, 6 months, 1 year, and then annually. It includes

typing

waiting

and

drainage,

PRESENT

patient observations. Observations are entered into the patient’s chart as a progress note. If medical or surgical house officers are involved, an effort

is made

the

THE

CARE

is consulted

antibiotics, to external

RADIOLOGIST

needs the support of skilled nurses for in-hospital and outpatient postprocedure care. A dedicated interventional radiology nurse is best suited to perform these functions as well as assisting with procedures in the laboratory. The nurse will be able to relate to the hospital nursing staff, instruct them in catheter maintenance, and report to the interventional radiologist when problems arise. During all inpatient rounds, the

nursing

for culture administration

con-

minutes.

interventional

Fur-

paten-

tinues to deteriorate despite appropriate measures, a code team should be called. It is important to remember that during a severe reaction, death

occur

weeks.

history and evaluation of pulse status and ankle-brachial pressure index.

syndrome.

with

patient’s

mit

Ste-

catheters

at 3-4

ther checks and prophylactic catheter changes take place every 6-12 weeks. The purpose is to maintain effective drainage and replace drainage catheters before they become obstructed and cause symptomatic infection. In patients with evidence of infection,

catheter

on the

on dis-

drainage

checked

therapeutic

lar-

treatment.

no effect

of the

occur,

replacement

bronchospasm,

with

first

appointment

the referring physician the service, and regular is established.

we take specimens Gram stain, start

material-in-

velopment

a pleasant

fluid

4) as a

contrast

allergic reaction, may help prevent

tion of the infected system (by contrast material injection) and by minimizing catheter and guide-wire manipulations. If this complication does rapid

nonionic

for contrast

will

The

most

intrave-

POSTPROCEDURE

to are

reIn

(Table

immediate given, they

Septic

related rare and

are

radiola history

an

follow-up

Patients

allergic

material (62).

substitute

use

edema,

may Reactions

is still

of an

duced reactions depends on the type of reaction. Isolated urticaria do not require treatment unless symptomatic. Generalized urticaria, angioneu-

roids

systolic).

Febrile Shock

we

given

charge unless is providing communication

of non-

cause

are

for outpatient

material

diphenhydramine

yngospasm

replacement indicates cardiogenic or septic shock or rapid blood loss. Once blood loss is excluded, dopamine infusion (Table 3) should be instituted and titrated to maintain an adequate perfusion pressure to vital organs

(>90

frequent

Therapy

an-

challenge. Since hypotension can precipitous, patients require close monitoring, as they may also have sociated cardiac or cerebrovascular compromise and tolerate hypotension poorly.

introduction

contrast

setting,

nous

3). renal

most

Patients

Anaphylactoid

of reaction to contrast ceives steroid prophylaxis

a hypertensive

successful

gioplasty

be

the

agents,

partments are generally not designed for such activity, and it might be necessary to rent space outside the department.

sup-

as dopa-

reaction in the interventional ogy practice. A patient with

should therapy.

hypotension

after

the

a pheochromocyto-

Vasodilatory velop

hy-

either

temporary

such

and

Despite

ionic cardiac

failure),

at times,

Anaphylaxis Reactions

10-20

(encephalopathy,

ischemia,

and,

port by a vasopressor, mine (Table 3).

pressure reOrally adminis-

de-

and

knowledge agusi,

Steven

the MD,

We are grateful

editorial

and

Lossef, Ayoob,

assitance

Barbara advice

given

Poulsen. given

the

review

MD,

Mark

by of the

for the by

Edith

We also Vincent

acF. Gar-

manuscript

Glass-Royal,

MD,

by

and

RN.

January

1991

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Radiology

#{149} 17