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Interventional Radiology Patient Management Safety

Conrad Killer

NUR4837 - Healthcare Policy and Economics

Dr. Maresca

6/18/23

Background

Policy #8

The Interventional Radiology (IR) department services patients who need procedures that can be done with imaging guidance requiring only small incisions. This field is currently growing in size and scope as technology advances and more procedures are shifting from general surgery to IR (Bart et al. 2023). This rapid expansion is paralleled by the increasing amount of patients on antiplatelet and anticoagulant therapy (AAT) due to both chronic comorbidities and sudden acute thrombotic events (Rosenberg, 2022).

This policy concerns the growing intersection of people that require IR procedures while on AAT. These individuals have a much greater risk of adverse events such as bleeds requiring blood transfusions during procedures (Rosenberg, 2022), because there are currently no laboratory tests to determine levels of newer anticoagulants within the patients’ bloodstream (Jensen & Erikson 2018).

Professional Background

My name is Conrad Killer. I graduated in 2020 from the Indian River State College Associate Nursing Program and began my career as a Registered Nurse at Stuart Rehabilitation and Healthcare on the Covid Unit. After 6 months, I took a position on the trauma and neurology unit at Lawnwood Regional Medical Center. Shortly thereafter, I transferred to the inpatient rehabilitation unit where I remained for two years.

For the past 9 months I have been an imaging nurse at Cleveland Clinic working closely with Interventional Radiology. My previous positions all showed me the devastating power of ischemic strokes, hemorrhagic strokes, pulmonary embolisms, pneumothoraxes, and pleural effusions. I cared for people who would never walk, eat, or speak again. In my current position, I finally feel as though I can do something to save these people so they do not have to endure the fate shared by my other patients.

Why this matters to me

What is at stake?

The Need

Pertinent data

  • Major bleeding post-procedure occurs in 0.4-5% of IR cases with AAT as a major risk factor (Mayer et al. 2015).
  • 10% of patients on long term AAT will require surgery annually (Patel et al. 2019).
  • Fatality rates of thrombotic events with associated diagnosis (Patel et al. 2019):
  • 17.5% for mechanical heart valve thrombosis.
  • 5%–10% for venous thromboembolism (VTE).
  • 37% for embolic stroke.

Some of these patients are unable to have certain procedures, because they are on AAT for their other comorbidities. These patients must hold their AAT medications for a minimum amount of time or else they risk a hemorrhagic event, but withholding their medications for extended durations will increase their risk of a thromboembolic event (Patel et al. 2019). This leaves a small window of time where a procedure can be safely performed. This policy aims to unify IR departments on a national level to best utilize that window thereby reducing the number of adverse events in the future.

The Proposed Policy

All patients scheduled for any IR procedure must be evaluted for hemorrahgic risk. If the patient and procedure are both not a high risk for bleeding, then they may continue their current AAT as normal. If either the patient or procedure are determined to be high risk, then AAT must be held for the corresponding number of days for the medication.

The Policy

Patel et al. 2019

Risk factors for bleeding

Hemorrahgic Risk

A patient is considered to be a high risk for bleeding if they possess three or more of the following:

  • Prior bleeding within 3 months, with similar type of procedure, or with bridging therapy
  • History of major bleeding or predisposition to bleeding
  • INR above therapeutic range at time of procedure or labile INR defined as time in therapeutic range < 60%
  • Concomitant use of antiplatelet agent
  • Chronic Hypertension
  • Mechanical mitral heart valve
  • History of alcohol or drug use
  • Prior hemorrahgic stroke
  • Abnormal renal function
  • Abnormal liver function
  • Platelet abnormality
  • Active cancer
  • Age > 65

The following are procedures that are considered to have a high risk of bleeding complications:

  • Ablations
  • Arterial interventions
  • Venous interventions
  • Biliary interventions
  • Urinary tract interventions
  • CNS interventions
  • Catheter directed thrombolysis
  • Deep abscess drainage
  • Deep nonorgan biopsies
  • IVC filter removal
  • Portal vein interventions
  • Solid organ biopsies
  • Spinal procedures
  • Transjugular intrahepatic portosystemic shunt
  • Gastrostomy/gastrojejunostomy placement

(Patel et al. 2019)

Below are the recommended withholding durations before high risk IR procedures per the Society for Interventional Radiologists (Patel et al. 2019). These durations will provide the lowest risk of both thrombotic events and major bleeding events for high risk patients and procedures.

AAT Medication Managment

Do not withhold - Cilostazol (Pletal)

1 hr - Cangrelor (Kengreal)

4 hr - IV heparin, Argatroban (Acova), Bivalirudin (Angiomax),

6 hr - Subcutaneous heparin

8 hr - eptifibatide (Integrilin), tirofiban (Aggrastat)

24 hrs - Long-acting abciximab (ReoPro), Enoxaparin (therapeutic dose)

1 dose - Lovenox (prophylactic), Dalteparin,

2 doses - Edoxaban (Savaysa), Rivaroxaban (Xarelto)

3 doses - Betrixaban (Bevyxxa)

4 doses - Apixaban (Eliquis), Dabigatran (Pradaxa)

3 days - Fondaparinux (Arixtra)

5 days - Aspirin 325mg, Aspirin/dipyridamole (Aggrenox), Clopidogrel (Plavix), Ticagrelor (Brilinta), Warfarin (Coumadin)

7 days - Prasugrel (Effient)

References

References

  • Bart, N., Mull, H., Higgins, M., Sturgeon, D., et al. (2023). Development of a Periprocedure Trigger for Outpatient Interventional Radiology Procedures in the Veterans Health Administration. Journal of Patient Safety, 19, 185-192. https://doi.org/10.1097/PTS.0000000000001110
  • Jensen, N. M., & Erickson, K. J. (2018). Risk Mitigation: Identifying and Creating Evidence-Based Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks. Journal of Radiology Nursing, 37(2), 103–106. https://doi.org/10.1016/j.jradnu.2018.02.004
  • Mayer, J., Tacher, V., Novelli, L., Djabbari, M., You, K., Chiaradia, M., Deux, J. F., & Kobeiter, H. (2015). Post-procedure bleeding in interventional radiology. Diagnostic and interventional imaging, 96(7-8), 833–840. https://doi.org/10.1016/j.diii.2015.06.009
  • Patel, I. J., Rahim, S., Davidson, J. C., Hanks, S. E., Tam, A. L., Walker, T. G., ... & Weinberg, I. (2019). Society of Interventional Radiology consensus guidelines for the periprocedural management of thrombotic and bleeding risk in patients undergoing percutaneous image-guided interventions-part II: recommendations: endorsed by the Canadian Association for Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe. Journal of vascular and interventional radiology: JVIR, 30(8), 1168-1184.
  • Rosenberg, K. (2022) Long-Term Anticoagulant Therapy Increases Bleeding Risk in Patients with Unprovoked VTE. American Journal of Nursing 122(1):p 59, DOI: 10.1097/01.NAJ.0000815444.12197.9c
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