Emergency Interventional Radiology Research Articles

Abstract WP40: Enhanced Team Communication Improves Door to Device Times

Background: Patients experiencing acute ischemic stroke benefit from early reperfusion. The American Heart Association set a goal for hospitals performing mechanical thrombectomy to achieve ‘door to device’ (DTD) time of less than 90 minutes for 50% of eligible patients. In 2021, only 23% of patients were meeting this time target. These patients require complex care and timely communication between various practitioners. It was noted that these practitioners were working in silos, which resulted in unnecessary delays. The need for enhanced communication was identified as an intervention to improve performance. Methods: Key team members are equipped with a dedicated phone using an artificial intelligence application, which provides an early signal when large vessel occlusion is detected. This allows for earlier mobilization of resources. This is particularly important for emergency department and interventional radiology nurses who are the ones driving transition of care between departments. In addition, the anesthesia department uses closed loop communication to notify the team of their readiness to receive the patient. Lastly, timely debriefs for all practitioners involved in the case provide a forum for constructive, thoughtful feedback about ways to be more efficient. Results: After enhanced communication strategies were implemented in quarter 2 of 2022, DTD times improved to 43% in quarter 3 of 2022, 50% in quarter 4 of 2022, 67% in quarter 1 of 2023 and 75% in quarter 2 of 2023. Conclusions: Providing tools to enhance communication amongst various practitioners has resulted in sustained improvement in DTD times. Future data collection should focus on associating these improved DTD times with long term functional outcomes.

Empiric Cryoprecipitate Transfusion in Patients with Severe Hemorrhage: Results from the US Experience in the International CRYOSTAT-2 Trial.

Hypofibrinogenemia has been shown to predict massive transfusion and is associated with higher mortality in severely injured patients. However, the role of empiric fibrinogen replacement in bleeding trauma patients remains controversial. We sought to determine the effect of empiric cryoprecipitate as an adjunct to a balanced transfusion strategy (1:1:1). This study is a subanalysis of patients treated at the single US trauma center in a multicenter randomized controlled trial. Trauma patients (more than 15 years) were eligible if they had evidence of active hemorrhage requiring emergent surgery or interventional radiology, massive transfusion protocol (MTP) activation, and received at least 1 unit of blood. Transfer patients, those with injuries incompatible with life, or those injured more than 3 hours earlier were excluded. Patients were randomized to standard MTP (STANDARD) or MTP plus 3 pools of cryoprecipitate (CRYO). Primary outcomes included all-cause mortality at 28 days. Secondary outcomes were transfusion requirements, intraoperative and postoperative coagulation laboratory values, and quality-of-life measures (Glasgow outcome score-extended). Forty-nine patients (23 in the CRYO group and 26 in the STANDARD group) were enrolled between May 2021 and October 2021. Time to randomization was similar between groups (14 vs 24 minutes, p = 0.676). Median time to cryoprecipitate was 41 minutes (interquartile range 37 to 48). There were no differences in demographics, arrival physiology, laboratory values, or injury severity. Intraoperative and ICU thrombelastography values, including functional fibrinogen, were similar between groups. There was no benefit to CRYO with respect to post-emergency department transfusions (intraoperative and ICU through 24 hours), complications, Glasgow outcome score, or mortality. In this study of severely injured, bleeding trauma patients, empiric cryoprecipitate did not improve survival or reduce transfusion requirements. Cryoprecipitate should continue as an "on-demand" addition to a balanced transfusion strategy, guided by laboratory values and should not be given empirically.

Major postpartum haemorrhage after frozen embryo transfer: Apopulation-based study.

To investigate the effect on major postpartum haemorrhage (PPH) of mode of conception, differentiating between naturally conceived pregnancies, fresh embryo in vitro fertilisation (fresh-IVF) and frozen embryo transfer (frozen-IVF). Retrospective cohort study. The French Burgundy Perinatal Network database, including all deliveries from 2006 to 2020, was linked to the regional blood centre database. In all, 244 336 women were included, of whom 240 259 (98.3%) were singleton pregnancies. The main analyses were conducted in singleton pregnancies, including 237 608 naturally conceived, 1773 fresh-IVF and 878 frozen-IVF pregnancies. Multivariate logistic regression models adjusted on maternal age, body mass index, smoking, parity, induction of labour, hypertensive disorders, diabetes, placenta praevia and/or accreta, history of caesarean section, mode of delivery, birthweight, birth place and year of delivery, were used. Major PPH was defined as PPH requiring blood transfusion and/or emergency surgery and/or interventional radiology. The prevalence of major PPH was 0.74% (n = 1749) in naturally conceived pregnancies, 1.92% (n = 34) in fresh-IVF pregnancies, and 3.30% (n = 29) in frozen-IVF pregnancies. The risk of major PPH was higher in frozen-IVF pregnancies than in both naturally conceived pregnancies (adjusted odds ratio [aOR] 2.63, 95% CI 1.68-4.10) and fresh-IVF pregnancies (aOR 2.78, 95% CI 1.44-5.35). We found that frozen-IVF pregnancies have a higher risk of major PPH and they should be subject to increased vigilance in the delivery room.

MP16-05 A NOVEL EMR-BASED CARE PATHWAY FOR NEPHROLITHIASIS: DEVELOPMENT AND 1 YEAR UTILIZATION

You have accessJournal of UrologyCME1 Apr 2023MP16-05 A NOVEL EMR-BASED CARE PATHWAY FOR NEPHROLITHIASIS: DEVELOPMENT AND 1 YEAR UTILIZATION Soum Lokeshwar, Daniel Heacock, Ankur Choksi, Devin Shaheen, Dylan Heckscher, Syed Rahman, Dinesh Singh, and Piruz Motamedinia Soum LokeshwarSoum Lokeshwar More articles by this author , Daniel HeacockDaniel Heacock More articles by this author , Ankur ChoksiAnkur Choksi More articles by this author , Devin ShaheenDevin Shaheen More articles by this author , Dylan HeckscherDylan Heckscher More articles by this author , Syed RahmanSyed Rahman More articles by this author , Dinesh SinghDinesh Singh More articles by this author , and Piruz MotamediniaPiruz Motamedinia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003236.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with acute renal colic due to stones frequently visit the ED. With limited ED resources due to the COVID-19 pandemic, we developed a best practice management pathway within our electronic medical records (EMR) to provide consistent, expeditious and appropriate care for patients with nephrolithiasis. The objective of this study is to describe the development and 1 year outcomes of our EMR Care Pathway for nephrolithiasis. METHODS: Our hospital system is composed of many centers. To standardize best practice care, we convened a clinical consensus group, with key stakeholders in emergency medicine, urology, interventional and diagnostic radiology to develop a pathway for the initial work up and management of acute renal colic. AUA guidelines, current literature, and expert consensus across specialties were used to develop the pathway to guide work up and management. Risk assessment tools, and criteria for specific imaging modalities, lab work, and pain protocols were outlined. Criteria for routine discharge with follow-up, including pre-populated links for referrals, indications for urology consult, hospital admission and urgent decompression (stent versus nephrostomy tube) were provided. Data was gathered through the EMR analytics team and descriptive statistics were performed. RESULTS: The Care Pathway was utilized 944 times from August 3, 2021 – September 17, 2022 at 11 different hospitals or care centers (Table 1). Usage increased overtime (r2=0.77). The majority of usage was in the ED (892, 94.4%). A total of 194 providers utilized the Pathway with the majority being residents (64, 33.0%). The pathway included care of 505 unique patients, with 106 primary diagnosis key words triggering pathway use. 139 Urology referrals were placed through the pathway with 124 new 28 day prescriptions of tamsulosin. CONCLUSIONS: An EMR-integrated care pathway has been readily utilized in our system and may augment triage and best practice management of patients presenting with stone disease. Further studies are needed to understand the full impact on outcomes. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e203 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Soum Lokeshwar More articles by this author Daniel Heacock More articles by this author Ankur Choksi More articles by this author Devin Shaheen More articles by this author Dylan Heckscher More articles by this author Syed Rahman More articles by this author Dinesh Singh More articles by this author Piruz Motamedinia More articles by this author Expand All Advertisement PDF downloadLoading ...

Management of Emergency Interventional Radiology Guided by Certified Nurse in Emergency Nursing

Management of Emergency Interventional Radiology Guided by Certified Nurse in Emergency Nursing

Ruptured ileocolic artery pseudoaneurysm after laparoscopic appendectomy for acute appendicitis

BackgroundA pseudoaneurysm of the splanchnic vessels is considered to be rare, and in particular, very few cases of pseudoaneurysm in the ileocolic artery are reported. Here, we report a case of rupture of a pseudoaneurysm of the appendicular branch of the ileocolic artery after laparoscopic appendectomy.Case presentationA 52-year-old man was diagnosed as having phlegmonous appendicitis, and an emergency laparoscopic appendectomy was performed. Bleeding from the inter-appendicular ligament during detachment of adhesions was stopped by white coagulation and Z-suture, and the inter-appendicular ligament was treated. The postoperative course was uneventful, and there were no adverse events or findings suggestive of abscess formation. On postoperative day 30, he presented with a ruptured pseudoaneurysm of the appendicular branch of the ileocolic artery. A definitive diagnosis was made by computed tomography, and emergency interventional radiology was performed with hemostasis achieved by coiling. The patient’s postprocedure course was favorable, and he was discharged with no adverse events, such as intestinal ischemia.ConclusionsWe experienced a case of delayed pseudoaneurysm rupture after laparoscopic appendectomy. Care must be taken when handling the appendicular artery during the procedure, and the potential for pseudoaneurysm formation should be considered at postoperative follow-up.

The management of dialysis access thrombosis during the COVID-19 pandemic.

Maintaining patent access is essential for haemodialysis dependent end stage renal failure patients. The COVID-19 pandemic has significantly affected surgical and interventional radiology services worldwide. We aimed to review the impact COVID-19 has caused to the management of acute dialysis access thrombosis. We conducted a single centre retrospective review of outcomes of patients with arteriovenous fistula and arteriovenous graft thrombosis between March and May 2020, which coincided with the first peak of the COVID-19 pandemic in London, and a similar period in the previous year, March-May 2019. Outcomes in both cohorts of patients were compared, including attempts at salvage, salvage success, 1-month patency rates after salvage and subsequent surgery on the same access. We also analysed the use of tunnelled haemodialysis lines (THL), either due to failed salvage attempts or when salvage was not attempted. There was a similar incidence of access thrombosis in both periods (26 cases in 2019, 38 in 2020). There were 601 patients dialysing via an arteriovenous fistula or graft in 2019, and 568 patients in 2020. Access salvage, when attempted, had similar success rates and 1-month patency (salvage success 74% vs 80%, p = 0.39; 1-month patency 55% vs 62%, p = 0.69). The proportion of patients where access salvage was not attempted and a THL inserted was significantly higher in 2020 compared to 2019 (32% vs 4%, p = 0.007). There were more patients who subsequently had surgery to salvage or revise the same access in 2019 compared to 2020 (62% vs 13%, p < 0.001). During the peak of the COVID-19 pandemic, there were fewer attempts at access salvage. This was a conscious decision due to increased pressure on the healthcare system, access to emergency interventional radiology or operative theatres and the perceived risk/benefit ratio of access salvage. The long-term effects of this change in practice remain unknown.

A Case of Human Immunodeficiency Virus-Positive Patient Diagnosed during the Treatment of Right Internal Iliac Pseudoaneurysm.

Isolated internal iliac artery aneurysms are rare, and there are no reports of human immunodeficiency virus (HIV)-related vasculitis in Japan. We report our experience with a 51-year-old man diagnosed with acquired immunodeficiency syndrome, discovered during the postoperative course when the patient exhibited remittent fever and susceptibility to infection after emergency interventional radiology therapy for a right isolated internal iliac artery aneurysm. The patient had positive treponema pallidum particle agglutination test result before admission, and tests for sexually transmitted disease showed positive results for HIV H-1 antibodies. The repeated fevers were attributed to HIV infection-related susceptibility.

The first case of balloon-occluded retrograde transvenous obliteration and partial splenic embolization for gastric varices in situs inversus abdominus

Situs inversus abdominus is a congenital abnormality characterized by the mirror image positioning of the abdominal organs, making it difficult to diagnosis and treatment of many diseases. Here, we report a rare case of gastric varices in situs inversus abdominus patient. A 55-year-old man was diagnosed with F2-shaped gastric varices associated with alcoholic cirrhosis. Abdominal dynamic computed tomography showed situs inversus abdominus, and gastric varices with a gastrorenal shunt. Due to the complex anatomy, emergency interventional radiology during bleeding was extremely difficult. Therefore, after thorough consultation, we decided to treat gastric varices prophylactically by balloon-occluded retrograde transvenous obliteration. After treatment, the patient’s clinical course was generally good, with no adverse events, and the gastric varices disappeared. It is important to assess anatomical positioning using three-dimensional reconstruction computed tomography images before treatment, to adequately prepare, including selecting appropriate devices (i.e., catheters and sheath). Although preventive treatment of gastric varices is controversial, in cases with anatomical complexity, preventive treatment with sufficient preparation would be recommended. To the best of our knowledge, there are no reports of treatment for gastric varices in situs inversus abdominus patient. This case will serve as a reference for successful treatment in future cases.

Asymptomatic hepatic artery dissection early after living-donor liver transplantation with simultaneous splenectomy: two case reports

BackgroundHepatic artery dissection after liver transplantation is an uncommon morbidity. The onset mechanism and management for this disorder remain unclear. The present report describes the cases of two patients with hepatic artery dissection after living-donor liver transplantation (LDLT) with simultaneous splenectomy and provides new insight into the onset mechanism of this disorder.Case presentation: Case 1A 51-year-old man with liver cirrhosis caused by hepatitis B virus underwent LDLT with a right lobe graft and splenectomy simultaneously. The recipient’s right hepatic artery had partial dissection at the anastomosis site; therefore, his left hepatic artery was anastomosed. Contrast-enhanced computed tomography (CT) on postoperative day (POD) 27 showed dissection from his celiac artery to his left hepatic artery with bleeding in the false lumen. There was a risk of rupture of the false lumen; therefore, emergency interventional radiology and coil embolization of the false lumen were performed. The patient was doing well at 6 months after LDLT.Case 2A 58-year-old woman with liver cirrhosis caused by primary biliary cholangitis underwent LDLT with a left lobe graft and splenectomy simultaneously. Her hepatic artery had a dissection that extended from her left hepatic artery to the proper hepatic artery. The gastroduodenal artery was anastomosed. Contrast-enhanced CT on POD 8 revealed dissection from the celiac artery to the common hepatic artery as well as a pseudoaneurysm at the celiac artery. We managed the patient with conservative treatment and performed daily follow-ups with Doppler ultrasonography examination and serial contrast-enhanced CT. At the time of writing this report, the patient was doing well at 34 months after LDLT.ConclusionsPatients who have an intimal dissection at the anastomosis site and/or simultaneous splenectomy are at a higher risk of hepatic artery dissection. Most patients with asymptomatic hepatic artery dissections can be treated conservatively. Blood flow in the intrahepatic artery should be checked frequently using Doppler ultrasonography or contrast-enhanced CT soon after diagnosis.

Neuroanesthesia Practice During the COVID-19 Pandemic: Recommendations From Society for Neuroscience in Anesthesiology and Critical Care (SNACC).

The pandemic of coronavirus disease 2019 (COVID-19) has several implications relevant to neuroanesthesiologists, including neurological manifestations of the disease, impact of anesthesia provision for specific neurosurgical procedures and electroconvulsive therapy, and health care provider wellness. The Society for Neuroscience in Anesthesiology and Critical Care appointed a task force to provide timely, consensus-based expert guidance for neuroanesthesiologists during the COVID-19 pandemic. The aim of this document is to provide a focused overview of COVID-19 disease relevant to neuroanesthesia practice. This consensus statement provides information on the neurological manifestations of COVID-19, advice for neuroanesthesia clinical practice during emergent neurosurgery, interventional radiology (excluding endovascular treatment of acute ischemic stroke), transnasal neurosurgery, awake craniotomy and electroconvulsive therapy, as well as information about health care provider wellness. Institutions and health care providers are encouraged to adapt these recommendations to best suit local needs, considering existing practice standards and resource availability to ensure safety of patients and providers.

Usefulness of Virtual Fluoroscopy in Emergency Interventional Radiology.

Interventional radiology (IR) embolization requires image guidance to steer catheters to the site of bleeding, where embolic agents such as Gelfoam or coils are administered to stem blood flow. In addition to treating iatrogenic trauma, embolization is suitable for injuries precluding surgery such as blush-bleeding of the liver or kidney and for locating and treating intimal blood vessel tears. However, during hospital off-hours (such as nights and holidays), experienced IR personnel are not always available. In such situations, there is a dire need to build a coordinated IR team to treat seriously injured patients rapidly and reliably. This article reviews the current principles and techniques used in IR such as virtual fluoroscopy and their usefulness, and makes a convincing case for emergency IR.

Wilson Disease With Giant Splenic Artery Aneurysms Caused by Fibromuscular Dysplasia During Living Donor Liver Transplantation: A Case Report

Liver cirrhosis can cause splenic artery aneurysms (SAA) that pose a threat to patients undergoing liver transplantation. However, liver transplantation with multiple visceral artery aneurysms including giant SAA caused by arterial fragility has never been reported. We describe a 36-year-old man with decompensated liver cirrhosis due to Wilson disease that was complicated by giant SAA and multiple aneurysms in the bilateral renal arteries caused by fibromuscular dysplasia (FMD). The maximal diameter of the triple snowball-shaped SAA was 11 cm. We planned a 2-stage strategy consisting of a splenectomy with distal pancreatectomy to treat the SAA and subsequent living donor liver transplantation (LDLT) to address the liver cirrhosis. This strategy was selected to prevent fatal postoperative infectious complications caused by the potential development of pancreatic fistula during simultaneous procedures and to histopathologically diagnose the arterial lesion before LDLT to promote safe hepatic artery reconstruction. However, a postoperative pancreatic fistula did not develop after a splenectomy with distal pancreatectomy, and the pathologic findings of the artery indicated FMD. The patient underwent ABO-identical LDLT with a right lobe graft donated by his brother. Other than postoperative rupture of the aneurysm in the left renal artery requiring emergency interventional radiology, the patient has remained free of any other arterial complications and continues to do well at 2 years after LDLT.

Emergency Interventional Radiology

Emergency Interventional Radiology

First establishment of a new table-rotated-type hybrid emergency room system

The hybrid emergency room (hybrid ER) system was first established in 2011 in Japan. It is defined as an integrated system including an ER, emergency computed tomography (CT) and interventional radiology (IVR) rooms, and operating rooms. Severe trauma patients can undergo emergency CT examinations and therapies (surgeries) without being transferred. The hybrid ER system is attracting attention because trauma resuscitation using this system has been reported to potentially improve the mortality rate in severe trauma patients. In August 2017, we established a new table-rotated-type hybrid ER to facilitate surgical functions. Herein, we introduce a new table-rotated-type hybrid ER consisting of an IVR–CT–operating room system and discuss its efficiency and feasibility for trauma resuscitation, including surgery and IVR. This system includes four new concepts: (1) to secure a wide working space during trauma resuscitation by reconsidering the arrangement of the C-arm, (2) ensure an air-conditioned operating room in the hybrid ER, (3) adopt an operating table but not interventional radiology table, and (4) prepare a trauma bay with three additional beds for multiple victims. This hybrid ER system also adopted the rotated-type table to secure a wide working space during the resuscitation phase. The C-arm was located away from the patients and placed on the wall opposite to the CT gantry, in contrast to that in previous systems. If patients needed an emergency IVR, the table was just rotated, and the IVR could be conducted immediately. This improvement can secure a wide working space in the hybrid ER. Moreover, the patient table was also a surgical operating table, and the hybrid ER system had an air-conditioned operating room (class 10,000). In the anticipation of many trauma patients being transported to the ER, a new trauma bay with three additional beds next to the hybrid ER was established, which also had an air-conditioned operating room. This new rotated-type hybrid ER system facilitates efficient surgical functions during trauma resuscitation and can secure a wide working space for the medical team to immediately perform resuscitative procedures and IVRs without delay.

First installation of a dual-room IVR-CT system in the emergency room

Computed tomography (CT) embedded in the emergency room has gained importance in the early diagnostic phase of trauma care. In 2011, we implemented a new trauma workflow concept with a sliding CT scanner system with interventional radiology features (IVR-CT) that allows CT examination and emergency therapeutic intervention without relocating the patient, which we call the Hybrid emergency room (Hybrid ER). In the Hybrid ER, all life-saving procedures, CT examination, damage control surgery, and transcatheter arterial embolisation can be performed on the same table. Although the trauma workflow realized in the Hybrid ER may improve mortality in severe trauma, the Hybrid ER can potentially affect the efficacy of other in/outpatient diagnostic workflow because one room is occupied by one severely injured patient undergoing both emergency trauma care and CT scanning for long periods. In July 2017, we implemented a new trauma workflow concept with a dual-room sliding CT scanner system with interventional radiology features (dual-room IVR-CT) to increase patient throughput. When we perform emergency surgery or interventional radiology for a severely injured or ill patient in the Hybrid ER, the sliding CT scanner moves to the adjacent CT suite, and we can perform CT scanning of another in/outpatient. We believe that dual-room IVR-CT can contribute to the improvement of both the survival of severely injured or ill patients and patient throughput.

Impact of hospital volume on mortality in patients with severe torso injury

BackgroundWhether a positive volume-outcome relationship exists in the context of trauma remains controversial. Heterogeneity in the definition of hospital volume in previous studies is one of the main reasons for this inconclusiveness. We investigated whether hospital volume is associated with mortality in patients with severe torso injury using two different definitions of hospital volume. Materials and methodsThis retrospective cohort study used the Diagnosis Procedure Combination database in Japan. Patients who were admitted to tertiary emergency centers with severe torso injury and underwent emergency surgery or interventional radiology treatment for the torso injury upon admission from April 1, 2010 to March 31, 2014 were included. Hospital volume was defined as the annual number of admissions with severe torso injury (HV-torso) or the annual number of total trauma admissions (HV-all). The main outcome was 28-d mortality. Multivariable logistic regression models fitted with generalized estimating equations were used to evaluate relationships between hospital volume and 28-d mortality. ResultsOverall, 7725 patients were included. The 28-d mortality rate was 15.3%. The HV-torso was significantly associated with reduced 28-d mortality (adjusted odds ratio = 0.59; 95% confidence interval = 0.44-0.79). However, there was no significant association between the HV-all and mortality (adjusted odds ratio = 1.02; 95% confidence interval = 0.72-1.46). ConclusionsThe HV-torso was significantly associated with reduced mortality in patients with severe torso injury. In contrast, the HV-all had no significant relationship with their mortality. Regionalization of trauma care for severe torso injury may be beneficial for patients with severe torso injury.

Experience With Flexible Vaginoscopy, Insights From an Ongoing Quality Improvement Project

Vaginoscopy is a common procedure performed on prepubescent girls. It is considered a standard diagnostic procedure most often preformed in the operating suite under sedation or anesthesia. New technology now allows gynecologists to perform vaginoscopy in the office as easily as in the operating room. As a quality improvement project we evaluated the percentage of operating room vaginoscopy. Our goal is to decrease operating room vaginoscopy to 15%. With approval for a quality improvement project by our metropolitan, tertiary care children’s hospital, we proceeded to collect information for all patients undergoing vaginoscopy including both under anesthesia and in the office setting. We collected the indication for procedure, whether or not a child-life specialist was present, time of device within vagina, whether the procedure was successful, whether the patient subsequently went to the operating room and the pain analog scale post procedure if awake. Descriptive statistics were used to analyze the data. Twenty five total procedures have been performed over a six month time course including in the office setting, operating room setting, emergency room setting as well as awake and with sedation. Thirteen total procedures were performed in the office setting without sedation. Five procedures were performed under anesthesia in operating room without attempt in the office setting. Four procedures were repeated in the operating room for all reasons, including inability to tolerate in office (2), equipment malfunction (1), and need for biopsy (1). Average age of patient who completed the procedure awake was 8y10m. Average time of procedure (device within vagina) was 5minutes with the range of 1-12 minutes. Average visual analog pain scale of awake patients was 3.6 with a range of 0-10. Percentage of operating room vaginoscopy is 37.5% in the first three months of use. In the next three months of use, the percent was 37.5% performed in operating room under general anesthesia and 18.8% under conscious sedation in emergency room or interventional radiology suite. Our experience demonstrates that the in-office vaginoscopy using hand held endoscopy device is an excellent choice for certain patients. Appropriate counseling and preparation of patients and guardian is essential. Of the 25 procedures, 21 of the procedures were successful in the setting we attempted first. Four procedures were repeated in the operating room setting. Five procedures were performed with the primary setting in the operating room. Thirteen procedures were performed with the primary setting in the office or emergency room. All patients selected were successfully completed in the ambulatory setting and none were placed in observation or admitted after the procedure. Our data also supports the importance of patient selection and key nature distraction plays in success of the procedure. Our project is ongoing and cites a trend towards decreased necessity for vaginoscopies in the operating room as we investigate other avenues to decrease our operating room vaginoscopy procedure rate toward 15%.

Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level.

Trauma activation level is determined by prehospital criteria. The American College of Surgeons (ACS) recommends trauma activation criteria; however, their accuracy may be limited. Prehospital lactate has shown promise in predicting trauma center resource requirements. Our objective was to investigate the added value of incorporating prehospital lactate in an algorithm to designate trauma activation level. Air medical trauma patients undergoing prehospital lactate measurement were included. Algorithms using ACS activation criteria (ACS) and ACS activation criteria plus prehospital lactate (ACS+LAC) to designate trauma activation level were compared. Test characteristics and net reclassification improvement (NRI), which evaluates reclassification of patients among risk categories with additional predictive variables, were calculated. Algorithms were compared to predict trauma center need defined as more than 1 unit of blood in the emergency department; spinal cord injury; advanced airway; thoracotomy or pericardiocentesis; ICP monitoring; emergent operative or interventional radiology procedure; or death. There were 6,347 patients included. Twenty-eight percent had trauma center need. The ACS+LAC algorithm upgraded 256 patients and downgraded 548 patients compared to the ACS algorithm. The ACS+LAC algorithm versus ACS algorithm had an NRI of 0.058 (95% confidence interval [CI], 0.044-0.071; p < 0.01), with an event NRI of -0.5% and nonevent NRI of 6.2%. When weighted to favor changes in undertriage, the ACS+LAC still had a favorable overall reclassification (weighted NRI, 0.041; 95% CI, 0.028-0.054; p = 0.01). The ACS+LAC algorithm increased positive predictive value, negative predictive value, and accuracy. Over-triage was reduced 7.2%, while undertriage only increased 0.7%. The area under the curve was significantly higher for the ACS+LAC algorithm (0.79 vs. 0.76; p < 0.01). The ACS+LAC algorithm reclassified patients to more appropriate levels of trauma activation compared to the ACS algorithm. This overall benefit is achieved by significant reduction in overtriage relative to very small increase in undertriage. In the context of trauma team activation, this trade-off may be acceptable, especially in the current health care environment. Therapeutic/care management study, level III; prognostic/epidemiologic study, level III.

Percutaneous radiofrequency ablation of a bleeding pseudoaneurysm during CT-guided renal cancer treatment. A case report.

We describe a new emergency interventional radiology approach in percutaneous procedure complications. We present the case of an 81-year-old male with small renal cancer, approached with percutaneous radiofrequency ablation (RTA) and complicated by pseudoaneurysm bleeding of a renal artery branch. In the emergency setting, pseudoaneurysm was treated in the CT room by the same RTA needle, without any complications or local tumor recurrence during the next 6-month follow-up.