Hydromorphone Hydrochloride Use During Various Interventional Radiology Procedures-Pain Control and Adverse Events: A Case Series Audit Analysis.

INTRODUCTION: This project studied pain control and the development of adverse events before, during, and after the administration of hydromorphone hydrochloride for various interventional radiology (IR) procedures. METHODS: We performed a retrospective analysis of 100 patients (men = 58; women = 42) sedated with peri-procedural intravenous (IV) hydromorphone in association with various IR procedures. We stratified the procedures as follows: abscess drainages (M = 8; F = 8), arteriograms (M = 1; F = 0), biliary interventions (M = 3; F = 2), bone biopsies (M = 2; F = 2), non-bone biopsies (M = 26; F = 19), non-tunneled venous catheters (M = 1; F = 1), tunneled venous catheters (M = 7; F = 5), embolization (M = 4; F = 0), IVC filter placement (M = 1; F = 1), nephrostomy tube placement (M = 1; F = 4), and percutaneous nephrolithotomy tube placements (M = 4; F = 0). We recorded the pre-, intra-, and post-procedure pain scores [numeric rating scale (NRS) with 0 = no pain to 10 = most pain] for each of the stratifications. We also recorded the total dose of hydromorphone and midazolam hydrochloride received by each gender, as well as whether any men or women received either naloxone hydrochloride or any antiemetic. Lastly, the investigators recorded the development of hypotension following hydromorphone administration and/or hypoxia as well as the need for opioid-induced intensive care unit (ICU) admission. The investigators used unpaired, two-tailed t tests, and either Yates-corrected Chi-squares or two-tailed Fisher's exact tests for continuous and categorical variables, respectively. The difference was statistically significant if p < 0.05. RESULTS: There was no significant difference between men and women for either mean age (M = 50 years; F = 53.4 years) or mean pre-procedural pain scores (M = 1.31; F = 0.55). There was no statistically significant difference in numbers of men or women for each procedure stratification. The highest mean pre-procedure pain score was in men undergoing percutaneous nephrostomy tube placement (mean 5, SD 0). The highest mean intra-procedure pain score was in men undergoing abscess drainages (mean 2, SD 2.3). The highest mean post-procedure pain score was in men undergoing abscess drainages (mean 1.5, SD 3.5). The only mean scores that were significantly different between men and women were in pre- (M = 2.5; F = 0.6; p = 0.006) and intra-procedural (M = 2; F = 0.5; p = 0.0001) pain scores for abscess drainages. There was no statistically significant difference in the dose of either hydromorphone (M = 1.3; F = 1.3) or midazolam (M = 1.3; F = 1.3) administered. There was no statistically significant difference in opioid-induced nausea (M = 1; F = 3). One female experienced hypotension and one male experienced hypoxia within 6 h of hydromorphone administration. There were neither opioid-related ICU admissions nor naloxone administrations. CONCLUSIONS: This preliminary study indicates that IV hydromorphone ± midazolam may be a safe and effective analgesic and sedative combination for adult patients undergoing IR procedures.

Selective versus nonselective embolization versus no embolization in pelvic trauma: A multicenter retrospective cohort study.

BACKGROUND: Traumatic hemorrhage from pelvic fractures is a significant challenge, and angioembolization has become standard. Optimal treatment is undefined in two clinical scenarios. The first is in the presence of a negative angiogram. Can arterial embolization treat venous bleeding by decreasing the arterial pressure head? If the angiogram is positive, is nonselective embolization (NSE) or selective embolization (SE) better? The purpose of this study is to determine if embolization after a negative angiogram aids in hemorrhage control and when the angiogram is positive, which level of embolization is superior? METHODS: A multicenter retrospective review was conducted including blunt trauma patients with pelvic fractures who underwent angiography. Demographic and clinical data were compiled on all subjects. NSE refers to an intervention at the level of the internal iliac artery and SE is defined as any distal intervention. Theoretical complications of pelvic embolization are those thought to arise from decreased pelvic blood flow and will be referred to as embolization-related complications. Thromboembolic complications included deep vein thrombosis or pulmonary embolism. RESULTS: One hundred ninety-four patients met inclusion criteria. Of the 67 patients with a negative angiogram, 26 (38.8%) were embolized. In those patients requiring transfusion, the units given in the first 24 hours were decreased in the embolization group (7.5 vs. 4.0, p = 0.054). Embolization-related complications occurred more frequently in those not embolized (11.4% vs. 6.0%, p = 0.414).One hundred forty-five patients were embolized, 99 (68.3%) NSE and 46 (31.7%) SE. There were no significant differences in mortality or transfusion requirements. There was no difference in the rate of embolization-related complications (4.1% vs. 2.1%, p = 0.352). There was a significantly increased rate of thromboembolic complications in the NSE group (12.1% vs. 0, p = 0.010). CONCLUSION: Embolization in the face of a negative angiogram may aid in hemorrhage control for those patients being actively transfused. If embolized, then selective occlusion of more distal vessels rather than of the main internal iliac artery should be performed. LEVEL OF EVIDENCE: Therapeutic, level IV.

The Close Exposure to Radiology Program: Educational Benefits to Medical Students.

BACKGROUND: Radiology clerkships during medical school provide a suboptimal training experience in the Chinese medical doctor training program. Staff radiologists are heavily occupied with clinic tasks which decreases teaching quality. The close exposure to radiology program (CERP) is a novel pathway designed to improve teaching quality, yet students' expectations of the potential benefits of such a program and their willingness to join CERP still have not been investigated among Chinese medical students. METHODS: A survey was conducted among medical students of both sexes with various majors and at different levels of training. The students were asked to identify the potential benefits of CERP as well as to indicate if they were willing to join CERP. RESULTS: Of the 1,600 surveys distributed to medical students, 1,394 were returned and analyzed. Most of the returned surveys were from males (1,268, 91%), and most respondents had not had a radiology clerkship experience (1,376, 99%). Most responding students were in a 5-year training program (94%) and in their third grade of training (41%). More than 60% of the surveyed students acknowledged each of the 5 benefits listed on the survey, although no statistically significant differences were seen between sexes, training grades, those with and without prior radiology experience, program length, or majors in how the questions were answered. Students most willing to participate in CERP were those enrolled in a 5-year training program (71%) and those who had previous radiology clerkship experience (89%). Students least willing to join CERP were majoring in somatology medicine (54%) and medical psychology (55%), and only 45% of students in 8-year programs indicated a willingness to join CERP. Chi-square tests indicated that the willingness to join CERP was not associated with sex (χ2(df = 1393) = 128.6, P=1.00), training program (χ2(df = 1393) = 111.3, P=1.00), training grade (χ2(df = 1393) = 266.1, P=1.00), major (χ2(df = 1393) = 456.1, P=1.00), or previous experience with radiology (χ2(df = 1393) = 142.2, P=1.00). CONCLUSION: Medical students enrolled at Fourth Military Medical University developed an awareness of the potential benefits of CERP; however, this awareness did not correlate with their willingness to join CERP.

Sedation, analgesia, and local anesthesia: a review for general and interventional radiologists.

Radiologists, like other physicians, need to know how to use sedatives, analgesics, and local anesthetics; however, their exposure to patients requiring discomfort control is limited, not just during residency but also in postgraduate practice. The purpose of this article is to provide a reference guide for radiologists who need pertinent and ready information on discomfort control. The authors discuss policies and standards that the Joint Commission has established for sedation providers; also discussed are the clinical pharmacology and dosage recommendations for the sedative, analgesic, anesthetic, and reversal agents that radiologists are most likely to use. Monitored anesthesia care and patient-controlled analgesia pumps, and in what circumstances they may be appropriate, are discussed. Anesthesia consultations are not uncommon when a nonanesthesiologist needs either of these services. Stiff chest syndrome, serotonin release syndrome, and systemic toxicity due to local anesthesia, all life-threatening conditions that sedation and analgesia providers may encounter, are discussed. The causes of these conditions and their necessary treatments are included in the discussion, along with cases in which a nonanesthesiologist may need an anesthesia consultation. It is important to understand that the control of pain and anxiety are not mutually exclusive but can occur either separately or together; when an agent that controls anxiety and an agent that controls pain are given together, the overall effect is synergistic. It is also important to understand the concept of multimodal analgesia; this is the use of opioids and nonopioids together to take full advantage of the analgesic effects of each component while minimizing potential side effects. Radiologists are fully capable of providing effective and safe pain control on their own and with the assistance of an anesthesiologist.