UFE in Freestanding Outpatient Center (Office Based Lab) John C. Lipman, MD, FSIR Atlanta, Georgia
UFE in Freestanding Outpatient Center (Office Based Lab)
John C. Lipman, MD, FSIR
Atlanta, Georgia
John Lipman, M.D., FSIR
• Consultant/Advisory Board: Merit Medical
• Other: Educational Grant Support, Boston Scientific
Why OBL ?
• Patient Preference & Economic Pressures
• Patients prefer OBL to hospital:
• -Cleaner, easier/more convenient, less expensive, more personal care
• We prefer it:
• -Control the product, individualized service, much more efficient, don’t need hospital
Economic
• Hospital incentivized to shift care IP--OP
• Healthcare Cost & Utilization Project (HCUP) Barrett et al Jan 2016 brief #200
• -Compared Hospital Inpt vs. Outpt Ambsettings for 4 treatments for uterine fibroids
• -Shorter X (0.6 vs 2.3d) stays--- lower charges $25k v $28k (even much lower c OBL)
Results
• SIR 2008 Lipman J & Amir L • -514 consecutive UFE pts, 501 d’c/d same day,
13 following am• -No pt returned within 1 wk, no transferER• Lipman (unpublished) OBL opened 5/7/15• -439 (thru 3/31/16) consecutive UFE pts• -All d/c’d same day, no bounce backs, no
transfershospital
How? Perform UFE Outpatient• 1. Patient/Family Education (thorough consult, expectations,
what to call us, signed document)
• 2. Specific Pain Protocol
• 3. Physician availability (cell #, nurses call q 24)
• 4. Home support
Pain Post-UFE
• Pain following UFE
• -Severity of the pain unpredictable (Roth AR, Spies J JVIR 2000; 11:1047-52)
• -Cumulative effect of combination of opioid & NSAID (Parker RK Anesthesia 1994 80:6-12)
• -Anti-emetic also helpful
Pain Timeline Post UFE• Pain increase for ~2hrs
• (AMBULATORY)
• Plateaus for ~3-4 hrs
• (DISCHARGE)
• Decreases to a lower plateau over next 4-5hrs
• Decreases each day over the next week. (Kirsch R
Medscape Women’s Health 2002 Mar-Apr 7(2): 4)
Pain control• Possibilities:
• 1. (Spinal or epidural anesthesia) adds complexity, not felt necessary, ?chronic pain pt
• 2. Superior hypogastric nerve block
• 3. Transdermal fentanyl patch
• 4. IA Lidocaine
• 5. (Ibuprofen c embolic or ibuprofen loaded beads)
Superior hypogastric plexus block• Continuation of celiac & lumbar sympathetic plexuses.
Innervates pelvic viscera including uterus.• Spencer E Cliical & Periprocedural pain management for UAE. Semin Intervent
Radiol 2013 Dec; 30(4): 354-63.
• Rasuli P Superior hypogastric nerve block for pain control in outpatient UAE. JVIR 2004; 15: 1423-9.
• How to:
• 1. Place cath over bifurcation
• 2. 21g needle below umbilicus aimed @ L4/5 disc
• 3. Inject contrast: cephalocaudal “fan shape stain”
• 4. 10ml 0.25% bupivicaine mixed c 10ml NS
• Seizures (intravascular injection)
Superior hypogastric plexus block
Transdermal Fentanyl Patch• Indicated for chronic pain (?off label)
• Patch works for 72hrs
• Serious or life threatening hypoventilation can occur in pts who are not opoid-tolerant
• 25mcg and 50mcg
• Probably need 50mcg
Intrarterial lidocaine• Lidocaine mixed c contrast for runoffs, TACE, UAE
(750mg max dose)
• Keyoung JA (Spies) JVIR 2001 12(9):105-9
• -10ml 1% (200mg) in each UA pre-embo
• -Study terminated p 18pts, vasospasm
• Zhan S Eur Radiol 2005 15: 1752-6
• -6ml (2ml 2% & 4ml saline) (40mg) post embolization
• -No severe or very severe pain (no PCAs)
• -Pain scores sig lower for 1st 48 hrs
Ibuprofen
• Ibuprofen• 1. Mixing ketoprofen c PVA during embolization (Bilhom T & Pisco J
Pharmaceuticals 2010;3:1729-38)
• 2. Loading embolic c IB (Borovac, (Pelage J) J Controlled Release 2006
115(3):266-74)
• 3. Sustained release (Namur et al J Cont Release 2009 135(3):198-202).Sheep
model, therapeutic levels of IB in surrounding tissue up to 7d
What I Do
• Pre: Toradol iv, Scopolamine patch, Tylenol 1000mg iv
• During: Fentanyl/Versed (50-100mcg/2-4mg), dilaudidimmediately post for cramping
• Lidocaine 5ml 1%pf each UA
• Post Fentanyl iv,(Dilaudid/Robaxin im post),Tylenol 1000mg iv
• D/C: Oxycodone* (5mgq2prn,#15) & Toradol (10q6,)/Motrin (800q6) x5d, Zofran (4mg q6prn)/Phenergan (1pr and q8prn, #5).
Nausea• Pain and/or narcotics
• Compazine & Phenergan suppositories hard to find
• Zofran expensive and taken po (post discharge)
• Isopropyl alcohol (snifs of alcohol pads) Spencer K Isopropyl
alcohol inhalation as a treatment of post op nausea and vomiting. Plast Surg Nurs 2004; 24(4):149-54.
• -Works quicker than zofran (10’ v 30’)
• -Much cheaper than zofran
• -Can self-administer in transit or @ home
Summary: Outpatient UFE
• 4 components:
• 1. Need to thoroughly discuss expectations/plan for post-procedural care
• 2. Dedicated pain regimen
• 3. Physician/staff availability
• 4. Home support