Interventional Radiology Stroke Protocol

Interventional Radiology Stroke Protocol

(Neuro Endovascular Care [NEC] Team)

Stroke patient identified by MD after arrival in ED triage or by EMS in route to ED

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ED nurse calls stroke activation, which results in pages to:

·  Neurology Faculty (Dr. Busby)

·  Neurology Resident on call (643-1677)

·  Charge nurse

·  Lab

·  CT radiology

·  Neurosurgery Chief Resident (Dr. Desai 643-0623)

·  Radiology Resident

·  Pharmacy

·  Pulmonary

·  Code Team

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Neurology Resident assesses patient. Patients will always get CT angiogram and 90% will receive TPA

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Neurology Resident contacts Dr. Raghuram with patient information

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Dr. Raghuram decides to perform intervention

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Neurology Resident activates Stroke Endovascular IR Team (NEC) Code via ED dispatch at 21479 that sends code pages to:

·  COA (in charge of opening room 2 personally and starting x-ray-409-392-5491)

·  IR nurse on call

·  IR technologist on call

·  Neurosurgery resident on call

·  Anesthesia senior resident

·  ***Neurology Resident is responsible for calling ANS Faculty at 75003***

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Patient transported to IR Room 2 by ER personnel or transport team from floor

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Regular Hospital hours (0800-1700)à ~ 15 minutes After hours à ~ 40 minutes

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Mechanical Clot removal through Femoral Line

Key Points:

·  Consent: Many patients are aphasic, may understand and nod or shake head to questions but many are unable to give informed consent. We are pressed for time. The ER has been instructed to bring family members who have given consent in the ER for the procedure with them to IR so they can be available for anesthesia consent. When patient is unable to consent and no family is available double MD signature is indicated.

·  In regards to assessing patient and getting consent be aware that:

o  R sided strokes: patients usually are able to comprehend

o  L sided strokes: patient often are unable to comprehend

·  A-line is desirable, however, this should not hold up case start à first stick/quick. Otherwise Dr. Raghuram can provide access with a femoral arterial line. It is important to put extension tubing on the A-line and secure it well ( e.g. tape), the table will be moving as will the biplane C-arms and short tubing can result in the arterial line getting caught and pulled out!

·  Try to keep systolic at high baseline. Dr. Raghuram prefers the SBP to be in the 160s mmHg . Many patients will already be hypertensive upon arrival. For MAC, BP will likely remain in that range. GETA patients may need BP supported with pressors: ephedrine, phenylephrine or even norepinephrine. Patients should already have reliable IV lines. You will not have time to place a central line. After recanalization we should try and keep systolic pressure 120-130 mmHg.

·  Anesthesia type: Start off all cases with MAC. Per Dr. Raghuram 70% will be MAC and 30% GA. If you have a patient with subarachnoid hemorrhage and will need coiling patient will need to be intubated and placed under GA.

·  When undergoing GA use an ETT. GETA patients should ideally be extubated unless there was a complication or patient factors dictate continued intubation. A patient who does not require sedation to tolerate an ETT is easier to manage in ICU in regards to BP maintenance >160 mmHg.

·  ACT measurements will be done; ANS is responsible for attaining blood. IR tech will perform the measurement.

·  You may need the following medications:

o  Heparin

o  Protamine

§  The patient will be given heparin which you will reverse at the end with protamine

o  Remifentanil

o  Mannitol (rarely)

o  Integrillin- Eptifibatide- binds platelet glycoprotein IIb/IIIa receptors

§  Nurse is responsible for attaining and preparing

·  During the procedure: Make sure that the lines and the circuit tubing do not get caught by the moving C-arms. The bed and the biplane C-arms will move intra-op. Stay away from the moving areas. There is a monitor with the vital signs there for us to see. Have lead aprons and thyroid shields.

·  All patients will go to NCCU after case completion. The neurology resident takes over the patient and report needs to be given to this resident.

·  Manpower: anesthesia staffing can be an issue. We are NOT supposed to delay these cases. Thus pulling residents may be necessary. After hours pulling a resident from OB may be necessary.

Resources:

http://stroke.ahajournals.org/content/45/8/e138.full.pdf+html

http://bja.oxfordjournals.org/content/113/suppl_2/ii9.full.pdf+html

http://www.ajnr.org/content/early/2014/11/13/ajnr.A4159.full.pdf+html

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1933827