Interventional Radiology Suite Research Articles

Automating sedation state assessments using natural language processing.

Common goals for procedural sedation are to control pain and ensure the patient is not moving to an extent that is impeding safe progress or completion of the procedure. Clinicians perform regular assessments of the adequacy of procedural sedation in accordance with these goals to inform their decision-making around sedation titration and also for documentation of the care provided. Natural language processing could be applied to real-time transcriptions of audio recordings made during procedures in order to classify sedation states that involve movement and pain, which could then be integrated into clinical documentation systems. The aim of this study was to determine whether natural language processing algorithms will work with sufficient accuracy to detect sedation states during procedural sedation. A prospective observational study was conducted. Audio recordings from consenting participants undergoing elective procedures performed in the interventional radiology suite at a large academic hospital were transcribed using an automated speech recognition model. Sentences of transcribed text were used to train and evaluate several different NLP pipelines for a text classification task. The NLP pipelines we evaluated included a simple Bag-of-Words (BOW) model, an ensemble architecture combining a linear BOW model and a "token-to-vector" (Tok2Vec) component, and a transformer-based architecture using the RoBERTa pre-trained model. A total of 15,936 sentences from transcriptions of 82 procedures was included in the analysis. The RoBERTa model achieved the highest performance among the three models with an area under the ROC curve (AUC-ROC) of 0.97, an F1 score of 0.87, a precision of 0.86, and a recall of 0.89. The Ensemble model showed a similarly high AUC-ROC of 0.96, but lower F1 score of 0.79, precision of 0.83, and recall of 0.77. The BOW approach achieved an AUC-ROC of 0.97 and the F1 score was 0.7, precision was 0.83 and recall was 0.66. The transformer-based architecture using the RoBERTa pre-trained model achieved the best classification performance. Further research is required to confirm the that this natural language processing pipeline can accurately perform text classifications with real-time audio data to allow for automated sedation state assessments. Automating sedation state assessments using natural language processing pipelines would allow for more timely documentation of the care received by sedated patients, and, at the same time, decrease documentation burden for clinicians. Downstream applications can also be generated from the classifications, including for example real-time visualizations of sedation state, which may facilitate improved communication of the adequacy of the sedation between clinicians, who may be performing supervision remotely. Also, accumulation of sedation state assessments from multiple procedures may reveal insights into the efficacy of particular sedative medications or identify procedures where the current approach for sedation and analgesia is not optimal (i.e. a significant amount of time spent in "pain" or "movement" sedation states).

Interventional Imaging Systems in Radiology, Cardiology, and Urology: Energy Consumption, Carbon Emissions, and Electricity Costs.

Background: The energy demand of interventional imaging systems has historically been estimated using manufacturer-provided specifications rather than directly measured. Objective: To investigate the energy consumption of interventional imaging systems and estimate potential savings in such systems' carbon emissions and electricity costs through hypothetical operational adjustments. Methods: An interventional radiology suite, neurointerventional suite, radiology fluoroscopy unit, two cardiology laboratories, and two urology fluoroscopy units were equipped with power sensors. Power measurements logs were extracted for a single 4-week period for each radiology and cardiology system (all between June 1, 2022 and November 28, 2022) and for the 2-week period from July 31, 2023 to August 13, 2023 for each urology system. Power statuses, procedure timestamps, and fluoroscopy times were extracted from various sources. System activity was divided into off, idle (no patient in room), active (patient in room for procedure), and net-imaging (active fluoroscopic image acquisition) states. Projected annual energy consumption was calculated. Potential annual savings in carbon emissions and electricity costs through hypothetical operational adjustments were estimated using published values for Switzerland. Results: Across the seven systems, the mean power draw was 0.3-1.1 kW, 0.7-7.4 kW, 0.9-7.6 kW, and 1.9-12.5 kW in the off, idle, active, and net-imaging states, respectively. Across systems, the off state, in comparison with the idle state, exhibited a decrease in mean power draw of 0.2-6.9 kW (relative decrease, 22.2-93.2%). The systems had a combined projected annual energy consumption of 115,684 kWh (range, 3646-26,576 kWh per system). The systems' combined projected energy consumption occurring outside of the net-imaging state accounted for 93.0% (107,978/115,684 kWh) of projected total energy consumption (range, 89.2-99.4% per system). A hypothetical operational adjustment whereby all systems would be switched from the idle to off state overnight and on weekends (vs operated in idle mode 24/7) would yield potential annual savings in energy consumption of 144,640 kWh, carbon emissions of 18.6 MtCO2eq, and electricity costs of $37,896. Conclusion: Interventional imaging systems are energy intensive, with high consumption outside of image acquisition periods. Clinical Impact: Strategic operational adjustments (e.g., powering down idle systems) can substantially decrease interventional imaging systems' carbon emissions and electricity costs.

Hybrid operating room with ceiling mounted imaging system assisted pre-operative and intra-operative lung nodule localization for thoracoscopic resections: a 5-year case series

BackgroundVideo-assisted thoracoscopic (VATS) lung resections are increasingly popular and localization techniques are necessary to aid resection. We describe our experience with hybrid operating room (OR) cone-beam computed tomography (CT) assisted pre-operative and intra-operative lesion localization of lung nodules for VATS wedge resections, including our novel workflow using the hybrid OR cone-beam CT to re-evaluate patients who have undergone pre-operative localization for those who are unsuitable for intra-operative localization.MethodsRetrospective analysis of all consecutive patients with small (≤ 20 mm), deep (≥ 10 mm distance from pleura) and/or predominantly ground-glass nodules selected for lesion localization in the Interventional Radiology suite followed by re-evaluation with cone-beam CT in the hybrid OR (pre-operative), or in the hybrid OR alone (intra-operative), prior to intentional VATS wedge performed by a single surgeon at our centre from January 2017 to December 2021.Results30 patients with 36 nodules underwent localization. All nodules were successfully resected with a VATS wedge resection, although 10% of localizations had hookwire or coil dislodgement. The median effective radiation dose in the pre-operative group was 10.4 mSV including a median additional radiation exposure of 0.9 mSV in the hybrid OR for reconfirmation of hookwire or coil position prior to surgery (p = 0.87). The median effective radiation dose in the intra-operative group was 3.2 mSV with a higher mean rank than the intra-operative group, suggesting a higher radiation dose (p = 0.01).ConclusionsWe demonstrate that our multidisciplinary approach utilizing the hybrid OR is safe and effective. Intra-operative localization is associated with lower radiation doses. Routine use of cone-beam CT to confirm the position of the physical marker prior to surgery in the hybrid OR helps mitigate consequences of localization failure with only a modest increase in radiation exposure.

Prospective study examining the impact of cerebral angiography on quantitative pupillometer values in the interventional radiology suite

ObjectivesThe purpose of this pilot study was to obtain baseline quantitative pupillometry (QP) measurements before and after catheter-directed cerebral angiography (DCA) to explore the hypothesis that cerebral angiography is an...

Comparative study between the use of double J ureteric stents vs bander ureteric stents during robotic-assisted radical cystectomy with intra corporeal ileal conduit urinary diversion.

Robotic-assisted radical cystectomy (RARC) is fast becoming the standard of care with comparable oncological outcomes to open surgery for patients with muscle-invasive bladder cancer. Ileal conduit is by far the most popular means of urinary diversion following a cystectomy. Use of stents is common practice to reduce uretero-enteric anastomosis-related complications. In the current study, practice was changed from the use of Double J (DJ) stents to bander stent intraoperatively. The potential advantages of using bander stent are avoiding second surgery for stent removal and easier change under local anaesthetic in the interventional radiology department. To compare the incidence of blocked, slipped stents and rate of ureteroileal anastomotic stricture after RARC with intracorporeal ileal conduit between practices of using DJ stents and bander stents. Retrospective analysis of all the patients undergoing Robotic radical cystectomy and intracorporeal ileal conduit between June 2014 and August 2023 was done. Initially, all intracorporeal anastomosis were covered with DJ stents. The practice was changed to cover the anastomosis with bander stent in November 2020. Number of patients needing re-surgery for blocked, slipped stents and ureteroileal anastomotic stricture were analyzed and compared using Chi-square analysis and Fisher's exact test (P < 0.05). A total of 168 patients underwent RARC with intracorporeal ileal conduit between June 2014 and August 2023 of which 128 patents were diverted with DJ stents and 40 with bander stent. The mean age and the patient demographics between the two groups were comparable. Of the 128 patients who were diverted with DJ stents, 6 (4.7%) had blocked stents, 3 (2.3%) had slipped stents, and 3 (2.3%) developed ureteroileal stricture needing readmission and urgent invasive intervention to exchange the stent or nephrostomy tube, whereas only 1 (2.5%) of the 40 patients with bander stent had blocked stent which was changed under local anaesthetic in the interventional radiology suite with no slipped stents reported and 2 (5%) had ureteroileal stricture who needed nephrostomies. Intraoperative ureteric stenting using bander stent has the potential to reduce the incidence of stent-related complications, such as blockage, slippage, and ureteroileal anastomotic stricture, following RARC with intracorporeal ileal conduit urinary diversion. Additionally, managing bander stent-related complications is less invasive with lower rate of readmission postoperatively compared to managing DJ stent-related ones.

Ultrasound-guided percutaneous nephrostomy: Analysis of early complications in a prospective descriptive cross-sectional study at a tertiary care center

Background: Percutaneous nephrostomy (PCN) is a crucial intervention for urinary obstruction. Understanding indications, complications, and materials used enhances its clinical application. Objective: This study aims to identify PCN indications, assess tube types/materials, evaluate early complications, and determine PCN success rates, fostering improved outcomes and procedural refinement. Materials and Methods: This study was carried out in the interventional radiology suite of the Department of Radiodiagnosis and Imaging, Tribhuvan University Teaching Hospital (TUTH) on 74 patients for one year. Patients of all age groups who underwent PCN were included in the study. Indications for PCN were identified before the procedure using various imaging modalities like Ultrasonography (USG), Computed Tomography (CT) scan, and more. The type of approach, calyx punctured, the size of the tube chosen, and the type of the drain material were all recorded during the procedure or in the post-procedure note. The patients were evaluated daily, and USG was done in every patient after 48 hours of the procedure to evaluate in terms of any complications. Results: Ninety-eight PCNs were done on 74 patients, of whom 58 were males and 40 were females. The main reasons for PCN were calculus disease with hydronephrosis (44.9%), calculus disease with pyonephrosis (22.4%), and obstructive uropathy due to bladder or cervix carcinoma. The success rate for PCN on the first attempt was 89.8%, while 6.1% required two attempts and 4.1% needed more than two attempts. Complications included tube dislodgement (8.2%), urinoma (5.1%), major bleeding (3%), and retroperitoneal hematoma (1%). No new cases of sepsis occurred post-procedure. Conclusion: Percutaneous nephrostomy is a safe and simple procedure with low morbidity and no life-threatening complications.

Magnetic Compression Anastomosis of Benign Short-Segment Ureteral Obstruction

PurposeTo investigate the feasibility, safety, and effectiveness of magnetic compression anastomosis of benign short-segment ureteral obstruction. Materials and MethodsPatients referred for failure of ureteral double-J stent placement because of impassable benign ureteral obstruction were included. Eleven patients (11 ureters) with a mean age of 57.5 years (range, 19–85 years; 8 women) underwent ureteral magnetic compression anastomosis. All patients had indwelling nephrostomy catheters. In all patients, anterograde and retrograde ureteral stent placements were unsuccessful using either interventional or cystoscopic access. Ureteral magnetic compression anastomosis was performed as a 2-step procedure. In the first step, magnets were placed. In the second step, the stricture was traversed via magnetic compression anastomosis. Successful establishment of anastomosis and ureteral double-J stent placement were considered technical success. The mean time for complete magnetic adherence and fluoroscopy time for each procedure were recorded. ResultsFive patients (45%) had an ileal conduit. The technical success rate was 91% (n = 10/11). The mean time for magnetic adherence was 5.7 days (SD ± 1.3). The mean single-rotation fluoroscopy times during the first and second steps of the procedure were 9.45 minutes (SD ± 2.09) and 15.70 minutes (SD ± 2.62), respectively. Magnets were removed with the support of either balloon catheters (n = 9) or biopsy forceps (n = 2). No procedure-related adverse events occurred. ConclusionsMagnetic compression anastomosis of benign ureteral obstruction is feasible and safe and can be performed in an interventional radiology (IR) suite without the need for endoscopy.

Hysteroscopic Lysis of Complex Uterine Adhesions After Interventional Radiology-Guided Access

To demonstrate a novel surgical technique using hysteroscopic lysis of adhesions after interventional radiology (IR)-guided access in patients with severe intrauterine adhesions and challenging uterine access. This video illustrates the technique of the safe division of intrauterine adhesions after IR-guided access. Conventional hysteroscopic adhesiolysis might be inadequate or risky in cases of severely narrowed or obstructed uterine flow tract, possibly resulting in incomplete adhesiolysis, false passages, or uterine perforation. This video presents 2 cases from a tertiary center involving a multidisciplinary team of a reproductive surgeon and an interventional radiologist. The first case involves a 38-year-old with severe Asherman syndrome, who experienced unsuccessful attempt to treat adhesions that was complicated by a false passage. The second case involves a 39-year-old with recurrent severe Asherman syndrome and a history of unsuccessful attempts at hysterosalpingogram and conventional hysteroscopic lysis of adhesions. In the IR suite, the patient was put in a lithotomy position on the fluoroscopy table. A vaginal speculum was inserted exposing the cervix. The procedure was performed using intravenous sedation and topical anesthetic spray applied to the cervix. Using fluoroscopy, a balloon cannula was inserted through the cervix, followed by contrast injection to assess uterine access. If there is no route, transvaginal ultrasound-guided needle cannulation of the main portion of the uterine cavity would be performed, approximating as closely as possible to the expected route of the cervical canal. A guidewire followed by a locked loop catheter was advanced through adhesions into the uterine cavity. The catheter was left protruding from the cervix to guide the hysteroscope. The patient was then transferred to the operating room for the hysteroscopic procedure. Under the guidance of the intrauterine catheter, the adhesions were carefully lysed using cold scissors. The endometrial cavity and tubal openings were inspected to ensure complete adhesiolysis and exclusion of any other copathologies. IR guidance can provide a safe and effective approach to hysteroscopic lysis of adhesions in patients with challenging intrauterine adhesions and difficult uterine access, such as patients with severe Asherman syndrome, intractable cervical stenosis, uterine wall agglutination, previous adhesiolysis failure, marked fixed retroverted retroflexed uteri, and previous false passage or uterine perforation.

90Y Contamination in the Interventional Radiology Suite: VARSKIN Estimation of Skin and Eye Injury and Review of Mitigation Strategies.

Our objective was to demonstrate, through computer simulations, radiation exposure levels from a 90Y contamination event during radioembolization procedures to calculate the radiation doses from various contamination scenarios. We also provide reasonable safety protocols to prevent contamination and minimize radiation exposure during decontamination. Methods: Simulations were performed using the computer code VARSKIN+, version 1.0, to determine the amount of radiation exposure resulting from different contamination scenarios. Results: The annual radiation dose limit to the skin and the lens of the eye was exceeded within 23 s of exposure to a 44-MBq droplet. Double layers of surgical gloves and level 3 gowns provided some attenuation of radiation from 90Y contamination by reducing the dose rate by 39% and 44%, respectively. Two layers of surgical gloves offered the best ratio of radiation protection without compromising dexterity. Conclusion: This study demonstrated that radiation exposures during 90Y spills or contamination events can be considerable. Interventional radiology and nuclear medicine personnel must be mindful of the risks, follow strategies to prevent spills, and be familiar with recommended decontamination procedures for spills in the interventional radiology suite.

Low‐Field Portable Magnetic Resonance Imaging for Post‐Thrombectomy Assessment of Ongoing Brain Injury

Background Timely imaging is essential for patients undergoing mechanical thrombectomy (MT). Our objective was to evaluate the safety and feasibility of low‐field portable magnetic resonance imaging (pMRI) for bedside evaluation following MT. Methods Patients with suspected large‐vessel occlusion undergoing MT were screened for eligibility. All pMRI examinations were conducted in the standard ferromagnetic environment of the interventional radiology suite. Clinical characteristics, procedural details, and pMRI features were collected. Subsequent high‐field conventional MRI within 72±12 hours was analyzed. If a conventional MRI was not available for comparison, computed tomography within the same time frame was used for validation. Results Twenty‐four patients were included (63% women; median age, 76 years [interquartile range, 69–84 years]). MT was performed with a median access to revascularization time of 15 minutes (interquartile range, 8–19 minutes), and with a successful outcome as defined by a thrombolysis in cerebral infarction score of ≥2B in 90% of patients. The median time from the end of the procedure to pMRI was 22 minutes (interquartile range, 16–32 minutes). The median pMRI examination time was 30 minutes (interquartile range, 17–33 minutes). Of 23 patients with available subsequent imaging, 9 had infarct progression compared with immediate post‐MT pMRI and 14 patients did not have progression of their infarct volume. There was no adverse event related to the examination. Conclusion Low‐field pMRI is safe and feasible in a post‐MT environment and enables timely identification of ischemic changes in the interventional radiology suite. This approach can facilitate the assessment of baseline infarct burden and may help guide physiological interventions following MT.

The Impact of a Hands-On Interventional Radiology Training Course on Radiology Resident's Training: A Single Academic Institution Experience

Abstract Purpose The aim of this study was to investigate the outcomes of an instructional hands-on training course that introduces radiology residents to the essential tools and skills needed to perform basic interventional radiology (IR) procedures. Materials and Methods This study was performed over a single academic year at a single academic institution. A precourse survey was sent to all radiology residents to identify areas of weakness and potential opportunities for improvement. In view of the responses, a hands-on training course was designed to cover the basics of vascular and soft-tissue access, catheters, wires, embolics, and closure devices. The training was provided in a one-to-one setting by a single IR attending over a period of 45 minutes and was concluded with hands-on training on an ultrasound (US) vascular access phantom whenever possible. An anonymous postcourse survey was then distributed and the results were analyzed. Results The average reported comfort level with basic IR concepts prior to course attendance was 1.7 on a 5-point scale (1 = not comfortable, 5 = very comfortable). This increased to an average of 4 following the course. Ninety-three percent of residents reported they have more confidence getting into the IR suite and assisting in IR procedures following the course. Residents who had an opportunity to train on the US vascular access phantom gave an average response of 4.6 out of 5 to a question of how helpful the experience was in improving their US hand skills (1 = not helpful, 5 = extremely helpful). One hundred percent of responders reported that the course successfully met its goal. Finally, the overall responses were unanimously in favor of continuing the hands-on training course. Conclusion A personalized, cost-effective, hands-on training course can improve the IR training experience of radiology residents, especially in the early training phase. This model is of particular value for smaller to medium-sized academic institutions with limited financial and educational resources.

Management of massive airway hemorrhage associated with extracorporeal membrane oxygenation: A retrospective case series study.

Extracorporeal membrane oxygenation (ECMO) is an important means of treating patients with respiratory failure. Massive airway hemorrhage is a rare complication of ECMO, with high mortality. The aim of this study was to provide a reference for improving the success rate of treatment of this complication by analyzing and summarizing patient clinical data. We searched PubMed, Medline, and EMBASE databases for case reports of massive airway bleeding associated with ECMO from January 2000 to January 2022 and included one case treated at our facility. All patients were disconnected from the ventilator, and the endotracheal tube was clamped during treatment, resulting in complete airway packing for hemostasis. The clinical data of these patients were analyzed. Through searching and further screening, two works of literature reported four cases that met our inclusion criteria. Including our patient's case, five patients were included in this study (four adults and one neonate). The longest ECMO treatment time before bleeding was 14 days, and the shortest was 20 min. In all patients, conservative treatment was ineffective after a major airway hemorrhage. They were disconnected from the ventilator and the tracheal tube was clamped for 13-72 h. The four adult patients underwent bronchial artery embolization in the interventional radiology suite. All patients' bleeding stopped after treatment; they were successfully weaned off ECMO and discharged. Treatment measures to disconnect the ventilator and clamp the endotracheal tube with full support from ECMO are feasible for massive airway bleeding associated with ECMO. Early bronchial arteriography and embolization can prevent rebleeding.

Student perceptions of the use of three-dimensional (3-D) virtual reality (VR) simulation in the delivery of radiation protection training for radiography and medical students

BackgroundVR simulation-based learning is increasingly used in healthcare education to prepare students for clinical practice. This study investigates healthcare students' experience of learning radiation safety in a simulated interventional radiology (IR) suite. MethodRadiography students (n = 35) and medical students (n = 100) were introduced to 3D VR radiation dosimetry software designed to improve the learners' understanding of radiation safety in IR. Radiography students underwent formal VR training and assessment, which was complemented with clinical placement. Medical students practiced similar 3D VR activities informally without assessment. An online questionnaire containing Likert questions and open-ended questions was used to gather student feedback on the perceived value of VR-based radiation safety education. Descriptive statistics and Mann–Whitney U tests were used to analyse Likert-questions. Open-ended question responses were thematically analysed. ResultsA survey response rate of 49% (n = 49) and 77% (n = 27) was obtained from radiography and medical students respectively. Most respondents (80%) enjoyed their 3D VR learning experience, favouring the in-person VR experience to online VR. 73% felt that VR learning enhanced their confidence across all relevant learning outcomes. Whilst confidence was enhanced across both cohorts, VR learning had a greater impact on confidence levels amongst medical students with respect to their understanding of radiation safety matters (U = 375.5, p < 0.01). 3D VR was deemed a valuable assessment tool. ConclusionRadiation dosimetry simulation-based learning in the 3D VR IR suite is perceived to be a valuable pedagogical tool by radiography and medical students and enhances curricula content.

175 Patient Safety Indicator 04 Does not Consistently Identify Failure to Rescue in the Neurosurgical Population

INTRODUCTION: Patient safety indicator (PSI) 04 is a quality index designed by the Agency for Health Research and Quality to measure Failure to Rescue (FTR). PSI 04 has been scrutinized for inaccurately measuring FTR, a framework developed to capture a hospital’s ability to identify and manage preventable complications and post-operative mortality. METHODS: We conducted a single-center retrospective cohort study. We identified patients from 1/12/2017-6/1/2021 who sustained a PSI 04-attributed complication (pneumonia, deep venous thrombosis/pulmonary embolism (DVT/PE), sepsis, shock/cardiac arrest, or gastrointestinal (GI) hemorrhage/acute ulcer), underwent a neurosurgical procedure, and had inpatient mortality. The primary outcome was whether the attributed PSI 04 designation was the primary driver of mortality. RESULTS: We identified 67 patients who met PSI 04 criteria (median age, 61; female sex, 43.4%). Nearly 20% of patients met the PSI complication criteria prior to admission. Patients who underwent emergent bedside procedures were more likely to present with poor GCS (P = 0.016), more likely to be intubated prior to admission (P = 0.016), and less likely to have mortality due to a PSI 04-related complication (P = 0.002). PSI 04-related complications were identified as the cause of death in only 43.2% of cases. Procedures occurring in the interventional radiology suite (OR, 23.2; 95% CI, 3.5-229.3; P = 0.003) or the operating room (OR, 6.2; 95% CI, 1.25-39.5; P = 0.03) were more likely to have mortality due to a PSI 04-related complication compared to bedside procedures. CONCLUSIONS: Most neurosurgical procedures meeting PSI 04 criteria took place outside of a traditional operating room and may capture a fundamentally different patient population. 65.7% of patients were inappropriately flagged as meeting PSI 04 criteria. PSI 04 currently identifies patients with complications unrelated to operating room procedures. Improvement in patient safety within neurosurgery necessitates the development of a subspecialty specific measure to capture FTR.

Bladder Assessment and Management in Acute Stroke Patients

ObjectivesAcute stroke patients are at high risk for morbidity and mortality. Their many comorbidities, including cardiovascular and renal diseases, require the attention of multiple medical and surgical teams in a compressed amount of time. Peristroke urinary retention can be avoided with an indwelling catheter. However, placement of a urinary catheter prolongs door-to-revascularization time, can lead to traumatic bleeding, and increases the risk of catheter-associated urinary tract infections (UTIs). We performed a quality improvement project to quantify the number of interventional thrombectomy stroke patients undergoing bladder drainage and track potential adverse effects. Materials and MethodsWe completed a retrospective chart review of acute stroke patients who required emergency endovascular thrombectomy between January 5, 2021, and November 1, 2021, at our institution to analyze our standard urinary management for acute stroke patients requiring interventional thrombectomy. ResultsWe identified 53 patients with acute stroke requiring interventional thrombectomy. An indwelling urinary catheter was inserted for 34 patients (64.2%) in the emergency department (ED) (4 [11.8%]), interventional radiology suite (12 [35.3%]), or postprocedural neurointensive care unit (NICU) (18 [52.9%]). Seventeen patients (32.1%) received bladder ultrasonography in the ED (mean volume, 342 mL) or NICU (mean volume, 433 mL). Two patients (3.8%), both catheterized, developed symptoms of UTI within 30 days. ConclusionsFrom our initial data, we could not discern a definitive treatment algorithm to determine which patients should receive a urinary catheter. Further investigation is needed to evaluate the role of portable bladder ultrasonography in the decision to catheterize ischemic stroke patients.

Time-Driven, Activity-Based Costing to Reduce Interventional Radiology Suite Idle Time.

Background With the ever-increasing complexity of today's healthcare environment, it is evident that there is a higher demand to deliver high-quality, accessible, efficient, and affordable healthcare. At the same time,these changes are accompanied by decreasing rates of reimbursement. This can be attributed to the shift from fee-for-service to value-based payment methods in the industry. The reception of such changes in the appropriate manner is crucial to improvement and the much-demanded reform in our healthcare system. To adapt to this changing landscape, hospitals and healthcare systems must incorporate proper measures to identify extraneous spending, control costs, and streamline patient care. Our goal in this study was to use the time-driven, activity-based costing (TDABC) model to quantify the costs at every step as an inpatient goes through the care process in an interventional radiology department. Methodology After identification and mapping of all the steps involved from interventional radiology (IR) consult placement to patient transport to the postoperative recovery area, time data were collected for each step of the process. One of the steps was then selected for intervention.Our focus was on the time interval between one patient leaving after a completed procedure and the next scheduled patient entering the IR suite (heretofore referred to as idle time). To decrease the idle room time between patients, the interventional radiologists, IR administrations, nurse manager, transportation manager, and charge nurse first met as a group to set a realistic initial goal. Pre-intervention data were collected. Results After the collection of pre-intervention data, the average idle time of the IR suite was found to be 40 minutes. After a multidisciplinary discussion, our goal was to reduce this time to 25 minutes. Post-intervention data found the average time decreased to 24 minutes. Calculation of average costs per unit time for staff, IR room, and equipment yielded an approximate cost of $57 per minute of time in the IR suite. Conclusions Considering the near 40% decrease in suite idle time as well as the cost per minute of material, equipment, and staff (at ~80% capacity), this study proves that the TDABC system is a viable method of targeting bottlenecks in operations and streamlining patient care by reducing costs while optimizing the process patients go through during care continuum.

Patient Safety Indicator 04 Does Not Consistently Identify Failure to Rescue in the Neurosurgical Population.

Improving neurosurgical quality metrics necessitates the analysis of patient safety indicator (PSI) 04, a measure of failure to rescue (FTR). To demonstrate that PSI 04 is not an appropriate measure for capturing FTR within neurosurgery. We conducted a single-center retrospective cohort study. Patients from January 1, 2017 to June 1, 2021, who sustained a PSI 04-attributed complication (pneumonia, deep vein thrombosis/pulmonary embolism, sepsis, shock/cardiac arrest, or gastrointestinal hemorrhage/acute ulcer), underwent a neurosurgical procedure, had inpatient mortality, and were identified using patient safety indicator 04 (PSI 04) tracking algorithm. The primary outcome was whether the attributed PSI 04 designation was the primary driver of mortality. We identified 67 patients who met the PSI 04 criteria (median age, 61 years; female sex, 43.4%). Nearly 20% of patients met the PSI complication criteria before admission. Patients who underwent emergent bedside procedures were more likely to present with a poor Glasgow Coma Scale ( P = .016), more likely to be intubated before admission ( P = .016), and less likely to have mortality due to a PSI 04-related complication ( P = .002). PSI 04-related complications were identified as the cause of death in only 43.2% of cases. Procedures occurring in the interventional radiology suite (odds ratio, 23.2; 95% CI, 3.5-229.3; P = .003) or the operating room (odds ratio, 6.2; 95% CI, 1.25-39.5; P = .03) were more likely to have mortality because of a PSI 04-related complication compared with bedside procedures. In total, 65.7% of patients were inappropriately flagged as meeting PSI 04 criteria. PSI 04 currently identifies patients with complications unrelated to operating room procedures. Improvement in patient safety within neurosurgery necessitates the development of a subspecialty specific measure to capture FTR.

Trauma Hybrid Operating Room (THOR) shortened procedure time in abdominopelvic trauma patients requiring surgery and interventional radiology procedures

IntroductionAbdominopelvic injuries are common, and bleeding occurring in both cavities requires various bleeding control techniques i.e., laparotomy, angiographic embolization (AE), and orthopedic fixation. Hence, the use of Trauma Hybrid Operating Room (THOR) in abdominopelvic injuries has theoretical advantages including rapid bleeding control and minimizing patient transportation. The objective of the present study is to evaluate the impact of THOR in abdominopelvic injuries. MethodA pre-post intervention study of abdominopelvic injury patients requiring both surgery and interventional radiology (IR) procedures for bleeding control from January 2015 to May 2020 was conducted. The patients were divided into 2 groups, pre-THOR group (received surgery in OR and scheduled for IR procedures in a separate IR suite, before December 2017) and THOR group (received all procedures in THOR, after December 2017). The primary outcomes were procedure time (including transit time in the pre-THOR group) and mortality. ResultsNinety-one abdominopelvic trauma patients were identified during the study period, 56 patients in pre-THOR group and 35 patients in THOR group. Distribution of injuries was similar in both groups (59 abdominal injuries, 25 pelvic fractures, and 7 combined injuries). The bleeding-control interventions in both groups were 79 laparotomies, 10 preperitoneal pelvic packings, 12 pelvic fixations, 45 liver AEs, and 21 pelvic AEs. THOR group underwent significantly less thoracotomy (1 vs. 11, p = 0.036), more resuscitative endovascular balloon occlusion of the aorta (REBOA, 0 vs. 5, p = 0.014), and more pelvic AE (13 vs. 9, p = 0.043). The procedure time was significantly shorter in THOR group (153 min vs. 238 min, p = 0.030). Excluding the transit time in the pre-THOR group, procedure time was not significantly different (153 vs. 154 min, p = 0.872). Both groups had similar mortality rates of 34%, but the mortality due to exsanguination was significantly lower in THOR group (11% vs. 34%, p = 0.026). ConclusionsTHOR eliminated transit time, resulting in shorter procedure time in abdominopelvic trauma patients requiring bleeding-control intervention. Although overall mortality reduction could not be demonstrated, the mortality due to exsanguination was reduced in THOR group.

S1790 Portal Biliopathy in a Patient Who Underwent a Whipple Procedure With Portal Vein Reconstruction

Introduction: Portal biliopathy is a condition that is defined as abnormalities in the biliary tract due to portal hypertension. Some patients may present with abdominal pain, fever, jaundice, or pruritis. Rarely, portal hypertension secondary to portal vein abnormalities cause peri-biliary varices. We report a case of a patient with a peri-biliary variceal bleed due to portal hypertension from acquired portal vein stenosis. Case Description/Methods: A 59-year-old female with a past medical history of pancreatic ductal adenocarcinoma presented to the hospital with 5 days of Black tarry stools. Two years prior, she was diagnosed with pancreatic head adenocarcinoma and underwent a pancreaticoduodenectomy with portal vein reconstruction. Subsequent CT scans demonstrated post surgical portal vein stenosis. On admission, she denied fevers, abdominal pain, or hematemesis. Labs were notable for a hemoglobin of 5.7 g/dl, INR of 1.6, and bilirubin of 1.0 mg/dl. Physical exam demonstrated an abdominal fluid wave and melena on digital rectal exam. CT abdomen showed post Whipple anatomy, severe portal vein stenosis, large volume ascites, and extensive upper abdominal collaterals including peri-portal and peri-biliary varices. Upper endoscopy revealed blood in the afferent jejunal limb. Bleeding was found to be originating from the choledochojejunostomy. Multiple large visible vessels with stigmata of recent bleeding were visualized within the common bile duct. A single hemostatic clip was placed on one of the vessels, resulting in increased bleeding. Hemostasis was achieved with cyanoacrylate injection. The patient was transferred to the interventional radiology suite, where she underwent portal venography confirming severe stenosis of the porto-mesenteric confluence. Interventional radiology performed portal vein balloon dilation and stent placement. The patient had no further bleeding following the procedure (Figure). Discussion: Bleeding from peri-biliary varices is a rare cause of upper GI bleeding. In this case, non cirrhotic portal hypertension from acquired portal vein stenosis after pancreaticoduodenectomy led to clinically significant gastrointestinal bleeding. Portal biliopathy is an uncommon and late presentation in patients with extrahepatic portal vein obstruction. In many cases, patients present with signs and symptoms of biliary obstruction. Treatment of PB should involve a multidisciplinary discussion among various subspecialties including gastroenterology, interventional radiology, and hepatobiliary surgery.Figure 1.: A. Choledochojejunostomy with visible varices. B. Hemostatic clip placement with subsequent bleeding. C. Injection of cyanoacrylate glue with hemostasis. D. Portal venography demonstrating portal vein stenosis at the porto-mesenteric confluence.

S2663 The Eroding Ulcer

Introduction: Massive upper gastrointestinal (GI) bleeds can be life threatening. Common causes are peptic ulcer disease and esophagogastric varices. These, when presented, often can be managed endoscopically. Ulcers in the GI tract can, rarely, erode into major arteries including the splenic artery and cause bleeding that may need embolization or surgery to control. Here we report a case of a massive upper GI bleed. Case Description/Methods: Patient is a 65 year old male with PMH of alcohol abuse, drug use, bed bound who presented with reported hematemesis. Initially patient reported he drank red liquid prior and refused an endoscopy. A day into hospitalization he had another episode of hematemesis and hypotension and was transferred to the ICU. There he transfused and stabilized. He underwent an endoscopy discovering a gastric ulcer in the fundus. Epinephrine was injected with good effect and cautery was initiated with bipolar probe starting at the periphery of the visible vessel and on the edges of the ulcer. While performing cautery, the vessel in the ulcer started to hemorrhage causing red out and inability to visualize. He was intubated and started massive transfusion protocol. Interventional radiology (IR) and surgery was consulted. He had three cardiac arrests with rapid return of pulse. When he made it to the IR suite, underwent angiography which showing significant bleeding from mid splenic artery which was coiled (d). With the location the ulcer had eroded into the splenic artery causing a fistula. He recovered well and was later discharged from the hospital. He underwent a repeat endoscopy a few days later (a) and another a few weeks after discharge (b,c). Discussion: Often with vascular fistulas there is an initial small bleed followed by a more significant bleed as seen in this case. When encountering massive GI bleeding, one must keep enteric vascular fistulas in the differential and have interventional radiology and surgery engaged early. Presenting with a splenic artery aneurysm with bleeding is rare, 0.01 to 10.4% depending on literature. Hemorrhage is one of the most common presentation for splenic artery pseudoaneurysms with 47% of cases and mortality approaches 90% if not properly managed. This case reminds us to keep a broad differential and to involve IR and surgery early in a massive GI bleed.Figure 1.: A.Endoscopy post coiling with coil emerging from ulcer. B. Endoscopy after discharge. C. Endoscopy after discharge, coils still present from ulcer. D. Angiogram showing active bleeding.