kelowna...michael d. lenz cpc 1540-1600 putting myself back together after limb loss, ralph zaiser,...

Kelowna

19th Annual Vascular Nursing Conference

September 11-12, 2019 Coast Capri Hotel,

Kelowna, British Columbia

Wednesday, September 11, 2019

0700-0800 Registration/Breakfast0800-0805 Welcome & opening remarks, Cynthia Kettle NP0805-1010 Peripheral Arterial Disease (PAD)0805-0850 PAD - The balance of surgical intervention and

medical management, Jeffrey Pasenau MD

0850-0910 PAD Case Study: When the train comes off the tracks, Alana McLean, LPN

0910-0940 Chronic pain in the vasculopath; The pathway of the problem, Ruth Ringland NP

0940-1000 Complexities of care in end of life patients with critical limb ischemia, Melissa Heisey RN

1000-1010 Panel/Questions1010-1100 Break/ Exhibitors1100-1220 Quality Improvement1100-1120 Nurses’ self-care: The importance of caring for ourselves, Ann-Marie Urban RN

1120-1140 Quality in vascular nursing: A transparent and systems-based approach, Bertha Hughes NP

1140-1150 Panel/Questions1150-1220 Business Networking Meeting/Awards1220-1320 Lunch/ Exhibitors1320-1410 Management of Peripheral Artery Disease (PAD)1320-1340 Decreasing length of stay while improving patient outcomes, Wendy Bowles NP

1340-1400 Limb preservation: A case study, Phoebe Chometa RN

1400-1410 Panel/Questions

1410-1450 Break/ Exhibitors

1450-1615 Management of Amputation1450-1510 Post-amputation tibial bandage modality study- Removable rigid dressing,

Guylaine Nadeau RN

1510-1540 The benefits of limb protection and compression in new amputees, Michael D. Lenz CPc

1540-1600 Putting myself back together after limb loss, Ralph Zaiser, Patient Partner


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Announcements/ Remarks

Wine and Cheese Networking Session

Kelowna 19th Annual Vascular Nursing Conference

9/22/2019

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Chronic pain in the vasculopath:

The pathway of the problem

Ruth Ringland NP(F)

Chronic Pain Clinic Surrey BC

No disclosures

IASP Definition of Pain

An unpleasant sensory or emotionalexperience associated with actual or

potential tissue damage; or described in such terms.

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2 broad categories

Acute • tissue injury

• Quick onset short duration

• Varies in severity and intensity

• Common occurrence• cause and effect obvious ( post‐op /cut/ abrasion/ sprain

• Usually easily treated *

Chronic

• Continues a month or more beyond usual recovery period months or years

• Difficult to define onset

• Scientifically there is still an inadequate understanding of the pathophysiology of chronic pain

• Clinically chronic pain has the characteristics of a disease state

• disease of our pain sensing mechanisms

Nociceptive and Neuropathic Pain

•Nocioceptive• Results from activation of peripheral nociceptors in response to tissue injury

• nervous system is intact

•Neuropathic• Develops secondary to direct nerve injury.

• Caused by a malfunction of the nervous system, may be due to decreased nerve perfusion

• Nervous system not fully intact

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Pain Quality DescriptorsThe descriptors patients use are helpful to identify what

type of pain they are experiencing

Nociceptive

Descriptors Examples

Somatic Throbbing, aching, sharp, gnawing, constant , burning

Surgical pain, sprained ankle, burns, bone metastases

Visceral Dull, cramping, squeezing, deep aching

Pancreatitis, bowel obstruction, menstrual pain

Neuropathic Burning, shooting, tingling, electric or shock like, pins & needles, tingling

Diabetic Neuropathy

Trigeminal Neuralgia

Guillian Barre-Syndrome

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Chronic Pain & Impact of Pain on Daily Living

• Mood

• Relationships

• Activity

• Valued Life Roles

Angus Reid Poll found:

• 83 % say pain prevents them from doing everyday activities

• 57 % say pain contributes to depression and anxiety

• 23 % say life isn’t worth living

• 64 % would seek better treatment, if they could afford it.

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What is the “cost” of pain? Prevalence 1st 2nd 3rd 4th

Visual MSK CVS Pain

Costs-direct health care 1st 2nd 3rd 4th

CVS MSK Pain

Visits to MD 1st 2nd 3rd 4th

Resp Pain

Societal costs 1st 2nd 3rd 4th

Pain more than cancer, heart disease and HIV combined

28% of Emergency visits are due to chronic pain (2007) 7

Chronic pain is a costly problem in North America

• Pain costs almost $100 billion annually‐ plus

• Pain results in over 50 million lost workdays.

• 50% of chronic pain patients have lost a job due to their illness.

• Workers lose an average of 4.6 hours per week of productive time due to a pain condition.

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CHRONIC PAIN IN VASCULAR DISEASE

• Vascular disease covers a wide range of conditions, • arterial, venous, and lymphatic disorders,

• many of these being more common in the elderly.

• As the population ages, not only will the incidence of chronic pain for other sources increase the incidence of vascular disease will increase, with a consequent increase in the requirement to manage both acute and chronic pain in this patient population.


• Pain is a key feature of vascular disease, with a major impact on quality of life and function.

• Pre‐existing chronic pain and multiple associated co‐morbidities, such as impaired renal function, obesity, diabetes mellitus, cognitive impairment, and ischaemic heart disease, often complicate pain management in this patient group.


• Many vascular disease patients have had re‐ current hospital admissions and multiple surgeries.

• Uncontrolled pain, acute or chronic, will result in pathophysiological changes,

• including an increased stress response and activation of the autonomic system, which may be particularly detrimental in patients with vascular disease.

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• a complex range of mechanisms underpins pain in patients with vascular disease.

• Nociceptive, inflammatory, and neuropathic mechanisms may all occur.

• Recognition of the predominant pathophysiological process driving pain in individual vascular disease patients is essential for successful pain management

• the varied mechanisms warrant specific approaches to analgesic choice

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Goals of Pain Management Therapy

Improved Functional Status

Decreased Healthcare Utilization

Decreased Pain

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Triad of Chronic Pain Treatment

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Activity‐leisure and exercise ….

Medications / blocks/ surgery

….

Mood, beliefs, attitudes, life roles, relationshipsExpectations ….

Physiotherapy / occupational therapy ….

Bio Psycho Social

Pain assessment process

• should address• Types of pain

• Distribution of pain

• Patientʼs current pain state ( biopsychosocial)• Effects of patientʼs current treatment

• Appropriate tools available for pain evaluation

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Questions to ask

• location

• onset

• timing

• type

• associated factors ( sleep and mood also)

• alleviating factors

• aggravating factors

• radiation

• rating (difficult to use 0‐10)

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• precipitating factors

• perception, understanding

• previous treatments sought ( successes?)

• Patient goals ( realistic?)

• Patient plan

• Past history in managing pain : looking for previous successes, ‘failures’

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The importance of “FIFE”

FeelingsPain

Anxiety

Loss

IdeasRuined for life

Rest is best

Might as well give up now

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FearsPermanent pain

Progressive damage

Loss of job

Loss of status

ExpectationsMRI scan

Surgery

Cure?

Sample of a Simple Tool – Brief Pain Inventory

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Score 1 = Severity

• ADD the amounts of questions 3‐4‐5‐6

• Total is out of 40

Score 2 = Interference

• ADD the amounts of questions in item 9

• total is out of 70

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Score 1:5+5+5+5=20

Score 2:7+10+5+4+8+8+8= 57

Psychosocial Factors

• Psychological history –• Past history of trauma or abuse

• Co‐morbid depression and anxiety

• Coping styles• Avoidant verses active• Locus of control• Maladaptive strategies & substance abuse

• Eg: Catastrophizing, chemical coping, anger, passivity

• Family Involvement and Functioning

• Pain score and descriptors

• Patient goals

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Challenges

• Helping the patient differentiate between acute and chronic pain and the treatments : acute is the easy one

• Helping the patient with managing pain when a cure does not exist

• Identifying ways to manage pain by using a chronic pain treatment continuum

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Pain Management

• Multimodal:• Self management

• Psychological

• Cognitive Behavioural : distraction, music, biofeedback

• Physical: heat/cold; massage, TENS – many of which vascular patients must exercise caution

• Medications

• Nerve blockade

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Patient Teaching

• Chronic pain is a chronic disease, no matter the cause • there is no cure

• Diet, exercise, sleep, mood, coping strategies are critical many times, more so than medications.

• Medication can be helpful but this may not be true for everyone

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Myth : Chronic Pain is always responsive to Interventions

• The answer is not at the end of a needle

• An intervention may help to temporarily alleviate pain but it is the Self Management strategies, physical activity and non pharmacological strategies that will help in the long term.

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Myth : Chronic Pain is always responsive to medication

• Sadly there is no magic “ blue “ pill for chronic pain, many try varied regimes and do not achieve the result they were hoping for.

• Non pharmacological strategies can help everyone and need to be employed – as with any chronic condition.

• Example: A diabetic relying on insulin alone without diet and exercise changes and support from family and Health Care Provider does not fair as well as the person who has the non pharm strategies

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Non Pharmacological

• Humour and laughter

• Music therapy

• Distractions

• Reminiscence

• Leisure activities

• Yoga

• Drama class!

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• Art Therapy

• Relaxation therapy

• Peer support

• Spiritual support

• Aromatherapy

• Volunteer activities – eg animal support “Hugabunny”

Patient Teaching

• Include family if possible

• Use of pain scale/questionnaires

• Encourage patient to report pain/activity/mood/sleep

• Discuss misconceptions as needed:• such as fear of addiction, dependence with meds, or being judged in a variety

of ways

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“The probability of a person taking a community

self-management program increases 18 fold if it

is recommended by a health care professional.”

(Murphy et al., 2009, Arthritis and Rheumatism)

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Final thoughts

• Patients with vascular disease frequently experience pain and have a high risk for suffering from chronic pain.

• In the acute setting, pre‐emptive analgesic strategies are recommended where possible.

• Chronic pain in vascular patients is always complex, with patients often having multiple co‐morbidities.

Final thoughts

• Multidisciplinary pain management is important in maximizing pain relief, function, and quality of life for this patient group.

• Further pain research is needed to improve quality of life for patients with vascular disease in a number of areas, such as :

• studies of outcomes from major vascular surgery should include both acute and chronic pain measures;

• a better understanding is needed of the progression from acute to chronic pain, and how to prevent this;

• how best to manage established chronic pain syndromes in vascular disease.

Summary

Components of an effective approach to management:

• Comprehensive assessment of the patients understanding and experience of pain

• Consistent use of assessment tools

• Continuous reassessment & evaluation

• Customization (multimodal approach) & collaboration (involving interdisciplinary team).

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Questions Resources

• Managing your Pain before it manages you by DrMargaret Caudill • Available in the library system usually but also

Chapters or Amazon.

• Centre on Aging self management class: • CDSMP http://www.selfmanagementbc.ca

• You can order material to your office for free.

• PainBC ‐‐http://www.painbc.ca

• Canadian Pain Society Links page –http://www.canadianpainsociety.ca/en/links.html

• Canadian Pain Coalition ‐www.canadianpaincoalition.ca

• Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non‐Cancer Pain—

• http://nationalpaincentre.mcmaster.ca/opioid

•

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Resources• http://www.medschoolforyou.com

online resource and course for Persistent pain

• http://www.paincare.ca/

• Osteofit www.osteofit.org

• Tai Chi http://pacific.canada.taoist.org/

• The Pain Toolbox ��

•

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Some Patient recommended Apps

• Chronic Pain Tracker‐ ( free)

• WebMD Pain Coach ( free) – diary, tips journal

• Take a Break! – guided Meditations for Stress Relief ( free)

• Calm from www.anxietyBC.ca

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References

• Canadian National Opioid Guidelines

• Canadian Pain Society

• American Academy of Pain Management

• Pain – Journal of the IASP

• Up To Date

• Canadian Pain Coalition

• Medscape search

• ITunes Store

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References

National Pain Survey, conducted by Louis Harris and Associates for Ortho‐McNeil, 1999.

Chronic Pain in America: Roadblocks to Relief, conducted by Roper Starch Worldwide Inc. for the American Pain Society, the American Academy of Pain Medicine, and Janssen Pharmaceutica, January 1999.

Voices of Chronic Pain, conducted by American Pain Foundation, May 2006.

“JCAHO Focuses on Pain Management,” Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho.org/news+room/health+care+issues/jcaho+ focuses+on+pain+management.htm.

Stamatos, J., Painbuster: A Breakthrough 4‐Step Program for Ending Chronic Pain, First Edition, New York, NY: Henry Holt & Company, LLC, 2001.

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References

Americans Talk about Pain, conducted by Peter D. Hart Research Associates for Research!America, August 2003.

Pain in America: A Research Report, conducted by the Gallup Organization for Merck, June 1999.

Voices of Chronic Pain, survey released by the American Pain Foundation for Endo Pharmaceutical, June 2006.

Stewart, W.F., J.A. Ricci, E. Chee, D. Morganstein, & R. Lipton. “Lost Productive Time and Cost Due to Common Pain Conditions in the U.S. Workforce.” Journal of the American Medical Association, Vol. 290, No. 18, 2003, p. 2443‐2454.

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Complexities of palliative care in patients with end-stage

peripheral vascular disease.

Canadian Society of Vascular Nursing Conference Kelowna B.C.

September 11th, 2019

Melissa Heisey BAH, BScN, RN

Overview

• Defining palliative care – old vs. new model

• Roles and responsibilities of palliative care nurses

• How palliative care fits within the vascular patient population

• Why palliative care is underused within this patient population – clinician and patient perspectives

• Impact on nurses who care for these patients -patient example.

• Where do we go from here?

What is palliative care?

What is palliative care?

• “Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychosocial and spiritual problems” (WHO, 2002)

New vs. old model

Adapted from Lynn & Adamson, 2003

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Canadian Hospice Palliative Care Association Nursing Standards of Practice, 2014

• Provides relief from pain

• Affirms life

• Neither hastens nor prolongs death

• Integrates the psychological and spiritual

• Offers a support system

• Enhances quality of life

Interdisciplinary Team

• Patient

• Family • Nurses

• Nurse Practitioners

• Doctors

• Social Work

• Physiotherapy

• Occupational Therapy

• Speech Language Pathology

• Personal Support Workers

• Wound Care

• Spiritual Care

• Home Care

• Acute/Transitional Pain Services

• Bioethics

• Dietician

• Palliative care specialists

Does palliative care have a place in peripheral vascular disease? • Challenging care due to complex surgical interventions

and serious comorbidities (Wilson et al., 2017)

• Ketteler & Maxfield proposes peripheral arterial disease ”should gain a rightful place among palliative care diseases” (2009)

• In PVD the treatment of the condition is often palliative and reconstructive (Gibson & Kenrick, 1998).

• Not all revascularization procedures are successful.

– 14% of patients undergoing revascularization had “ideal result” (Santema et al., 2017).

Palliative care underused in vascular setting • 75% of people prefer to die at home

• 7% of patients with CLI returned home prior to their death (Campbell et al., 2000).

• Average of 3.5 days between the decision for palliative care and death (ibid).

• 20% of patients transitioned to “comfort care” received palliative care consultation.

Why is palliative care underused?

Patient Clinician

Clinician

• Many operative options are now available.

• Lack of advanced directives.

• Patients tend to be referred late to palliative care if at all.

• Palliative care often presented to patients as “end of life” care.

• Difficult to predict trajectory of PVD.

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Patient

- Unrealistic expectations about vascular interventions

- Lack of advanced care directives

- Too ill to contribute to discussion

- Avoidance or lack of acceptance of prognosis

- Misconceptions about palliative care

Impact on nurses

• Compassion fatigue

• Burn out

• Moral distress

Mrs. Y – A potential opportunity• Social history:

– Married

– 1 adult child

– Family very involved in patient’s care

• Past medical history:– Lupus

– Cervical cancer (requiring colostomy)

– Fem-fem bypass

– Bilateral AKAs

– Left Ax-fem bypass

– Tricuspid valve endocarditis (TVR)

– vaginal-rectal fistula

– MRSA positive

Mrs. Y

• Thrombosed fem-fem crossover: revision done, unsuccessful.

• Wound care: Stage 4 sacral ulcer – extensive VAC dressing every Monday & Thursday requiring PACU

• Pain: Patient in constant pain – oxycodone IR 30 mg q2hrs with 100 CR BID. Patient unable to be turned and repositioned more than once a shift due to pain.

Impact on 4A nurses• “I heard her sobbing like she had been for the past 2 mornings I was

looking after her, I just couldn’t do it. I couldn’t go in yet, I was tired. I needed 10 minutes to compose myself before I could handle being near that level of suffering.”

• “I just kept thinking it’s futile care… with every next surgery or consult, just what’s the point? Is she really satisfied with her quality of life or just in denial?...”

• “doing her dressing change at the bedside was a nightmare I can still hear her cry. It was her choice to get it done as part of the care but at the time I felt like I was torturing her.”

• “I spent one night shift rubbing her back even though I was behind on my work because it was the only thing I felt like I could do. I felt helpless which isn’t a good feeling because we are supposed to be helpful as nurses. She cried the whole time and I ended up having to leave the room because I was crying too.”

Where do we go from here?

• Rebranding palliative care

• Education

• Realistic expectations

• Advanced directives

• Determine individual patient goals

• Family meetings

• Take care of ourselves!

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References • Bakker, A.B., Le Blanc, P.M., Schauefl, W.B. (2005). Burnout contagion among intensive care nurses. Journal of

Advanced Nursing; 51(3): 203-317

• Campbell, W.B. (2000). Non-intervention in palliative care in vascular patients. British Journal of Surgery, 87: 1601-1602.

• Campbell, W.B., Verfaillie, P, Ridler, B.M. & Thompson, J.F. (2000). European Journal of Endovascular Surgery (19): 246-249.

• De Mestral, C., Hsu, A.T. et al. (November 2018). End-of-life care after major amputation for diabetes or peripheral arterial disease. Journal of vascular surgery; 68(5): 117.

• Gibson, J.M. & Kenrick, M. (April 1998). Pain and powerlessness: the experience of living with peripheral vascular disease. Journal of Advanced Nursing; 27(4): 737-45.

• Jameton, A. (June 2017). History of Medicine: What moral distress in hursing history could suggest about the future of health care. AMA Journal of Ethics, 19(6): 617-628.

• Ketteler, E.R. & Maxfield, K. O. (2009). Embracing the palliative care aspects of peripheral artery disease (PAD) the vascular surgeon’s perspective. Progress in Palliative Care: Science and the Art of Caring; 17(5: Palliative Surgery): 237-244.

• Lynn, J & Adamson, D.M. (2003). Living well at the end of life: Adapting health care to serious chronic illness in old age. Arlington VA: Rand Health.

• Lynn, J. Living long in fragile health: The new demographics shape end of life care. (2005). November-December Hastings Centre Report.

• Wilson, D.G., Harris, P. H. et al. (2017). Patterns of care in hospitalized vascular surgery patients at end of life. JAMA Surg; 152: 183-90.

• World Health Organization. (2002). National cancer control programmes: Policies and managerial guidelines. 2nd

ed. Geneva.

• Zimmermann, C. et al. Perceptions of palliative care among patients with advanced cancer and their caregivers. (2016). CMAJ; 188 (10): E217-E227.

THANK YOU

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Nurses’ Self-Care: The Importance of Caring for Ourselves

Canadian Society of Vascular Nursing Kelowna, BC September 11 & 12, 2019

Ann-Marie Urban, RN, RPN, PhD

Associate Professor

Faculty of Nursing

University of Regina

Nurses’ Work

Physical, emotional, chaotic, fast-paced, noisy, shift work, changing patient population (co-morbidities, bariatric, social & mental issues),

family expectations, death, interpersonal challenges, system priorities-expedited

workplace, staffing shortage, cost constraints, constant change...)

(Edward, 2005; Hamilton et al., 2010; Hodges, Keeley, & Grier, 2005, McAllister & McKinnon, 2009; Quality Worklife-Quality Healthcare

Collaborative, 2007)

“Stress levels making nurses ill” (Nursing Times, 2014)

Nurses

Physical and Emotional Toll (McVicar, 2007)

Skip breaks to finish their work and not burden others (Scott, Hofmeister, Rogness & Rogers, 2010)

Lack of exercise due to fatigue and no time (Sveinsdottir & Gunnarsdottir, 2008)

Average age of RNs in Canada 45.6 (Statista, 2018)

Nurses –Type E personality –Everything for Everyone (Anderson, 2017)

Acute Stress

Sudden, short-term –argument, traffic jams

S & S-↑B/P, HR, R, muscle tension

Keeps us alert, energizes us…

In short spurts, cortisol can boost your immunity by limiting inflammation.

But over time, cortisol can cause havoc on your body –recognizing this as NORMAL

Chronic StressLong-term stressors, repeated exposure,

predispositions (lifestyle, genetics)= health issues

Chronic activation of this survival mechanism impairs health

(Harvard Medical School, 2010)

Difficult for the parasympathetic NS to reset

Stress is part of life however being ‘stressed out’ is not

(McKewan & Lasley, 2002)

Self-Care

"the practice of activities that individuals initiate and perform on their own behalf in maintaining

life, health and well-being" (Orem, 1980)

“what people do for themselves to establish and maintain health, and to prevent and

deal with illness. It is a broad concept encompassing hygiene (general and

personal), nutrition (type and quality of food eaten), lifestyle (sporting activities, leisure etc), environmental factors (living conditions, social habits, etc.) socio-economic factors (income

level, cultural beliefs, etc.) and self-medication” (World Health Organization, 1998)

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Which one best describes your (YOUR self-care) practice? Like a cell phone do you….

A) I recharge myself every dayB) I recharge charge myself

when I’m lowC) I recharge myself when I’m

dead

Self-Care Action PlanSelf-care incorporates the spirit, mind (knowing and feeling) and body’s needs Preventative maintenance Looking at oneself honestly⇒identifying needs-responsibility= self careCommitment and time

Spirit, Mind and Body AssessmentRecognizing the Signs and Symptoms

MENTAL & SPIRITUAL: difficulty concentrating, memory and mood changes, nervousness, ↓energy, negativity, overwhelming feeling, sleep disturbances, lacking motivation and or zest for life

PHYSICAL: ↑ stress hormones-(↑cortisol, adrenaline, norephinprine), headache, pain, muscle tension, ↑ cholesterol levels and blood glucose levels, intestinal disturbances, muscle tension, weakened immune system, weight changes

Self-Care SPIRIT Strategies Develop your own spiritual side

Make a list of all of the individuals who make you feel more alive, happy and optimistic *they are important for your energy and healing

Practice forgiveness/letting go

Connect with nature (Zhang & Howell, 2014)

Use your sense of humour

Prayer, meditation, yoga (van der Riet, Levett-Jones & Aquino-Russell, 2018)

Self-Care MIND Thinking/Knowing Strategies

Brain/neuroplasticity (neural pathways-memory, attention, cognition, processing, learning) (Vance, Roberson, McGuiness & Fazeli, 2010)

Cultivate your curiosity

Take a class, learn an instrument, language, skill

Watch a program or listen to music you usually would not

Sudoku, crosswords, puzzles

Declutter the house (Kondo, 2014)

Self-Care MIND Emotional (Thinking –Feeling) Strategies

Develop self awareness- pay attention to your feelings

Understand your triggers

Learn to identify habitual thoughts/images that produce feelings of sadness, anxiety, anger (you are NOT your thoughts)

Stop saying negative things to yourself *I am ….

Give yourself permission for alone time-need to get away

Make sure there is a portion of your life in which you

take rather than give

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Self-Care BODY Strategies Activity –consistency-20-30 minutes three –four

times a week (30/30/30 & 10) ↑endorphins, metabolism, overall quality of life

Nutrition –nutrient dense-colour

Good: Fruits, vegetables, nuts/seeds, whole grains, polyunsaturated fats, seafood*omega 3’s

Bad: Processed meats, sugary drinks & foods

Sleep

Water (dehydration increases cortisol)

Relaxation time

Work Care StrategiesMake your needs knownCreating a ‘healing’ spaceContinuing education (education,

retreats, fitness programs, stress reduction, debriefing)

Laugh, celebrate together, listen to each other

Monitor your reactions to work situations–Discuss feelings with a trusted colleague, your manager

Notice your way of being with your co-workers-your body language- or not being present

Abdominal Breathing

Taking a few deep breaths engages the Vagus nerve which triggers a signal within your nervous system to slow your heart rate, lower blood pressure, improve

digestion and decrease cortisol (Landini, 2019)

Deep breathing helps boost your resistance to infection

(besides the physiological process of breathing-it provides a distraction from our thoughts)

Further Reading

Let Your Life Speak by Parker Palmer

The Wellness Book by Dr. Benson & Eileen Stuart (RN)

Transforming Nurses’ Stress and Anger by Sandra Thomas

When the Body Says No by Gabor Mate

Yoga Nidra by Kamini Desai

Caring for others requires caring for oneself

(Dalai Lama, 2003)

Practice proactive self-care…not reactive

Choose to think about what you want

rather than what you don’t want

Growth and change don’t happen in an instant

The only person you are destined to become is the person

you decide to be (Ralph Waldo Emerson)

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QUESTIONS

Please feel free to contact me

[email protected] Advocate

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Quality in Vascular Nursing: A Transparent and Systems‐Based Approach

Bertha Hughes NP‐Adult, MN, RVT. CCN (C), CDEVascular Surgery Nurse Practitioner

St. Michaels Hospital, Toronto, Ontario,

• To provide evidence of the value of Vascular Nursing Quality Rounds

• To demonstrate that a framework of openness, non‐judgement and professionalism will garner engagement of front‐line staff

• To provide clarity on the benefits of front‐line staff review and presentation of adverse nursing events

• To focus on improving processes as a method of optimizing care in Vascular Nursing practice

Objectives

Adhering to Legal Guidelines for Quality Rounds • For system quality improvement purposes ‐ be clearly titled “For Quality Improvement Purposes Only”

• Confidential ‐ they can’t be discussed by any member in that room or beyond that room.

• Only recommendations for changes can be written or shared.

• No discussion minutes to be taken and recommendations must focus on system quality improvement only.

• The information can’t be used in the course of legal actions or discipline of an individual related to practice or conduct.

• Performance issues should not be discussed in the M&M.

• If a performance issue is discovered, there should be no discussion about it in the room but rather identified to the manager as a potential incident to review that may relate to individual performance.

• No information from the M&M can be seen by the manager as part of the incident review for performance.

• Communications must originate in a confidence

that they will not be disclosed

• This element of confidentiality must be essential

to the parties’ relationship

• The relationship must be thought important

enough to protect

• The injury to the relationship by the disclosure

must be greater than the benefit gained by the

disclosure

Wigmore Test –criteria to be considered privileged

(Patrick Hawkins, Quality Assurance and Privilege Powerpoint Presentation, (BLG prepared for Osgoode PD LLM program, 2013) at 14. )

• QCIPA is a short but powerful piece of legislation

• It promotes and protects information needed by hospitals to promote quality improvement.

• It was driven by the need for improved patient safety in hospitals

• Critics say it offers a veil to protect hospitals

• QCIPA is needed and valuable in seeking accurate and honest information to improve quality of care

Quality of Care Information Protection Act (QCIPA)

(John, Morris. Law for Canadian Health Care Administrators, 2nd ed (LexisNexis Canada Inc., 2011) pages 144‐147.)

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Amazing Leadership Team

Tasha H&V Program Director

VictoriaCLM

KimH&V Educator

• Support of 4 hrs protected time for RN to review IAT event (they had submit)• Support of 4hrs protected time for RN to present the IAT event and recommendations to peers• Total cost $960

• Adverse events more often reflect gaps in systems and processes rather than in the individual

• Blaming individuals victimizes them twice‐once when the system failed them and again when the system accused them

Root Cause of Adverse events

(Zavotsky et al, 2018; Guger et al, 2011)

• Review of the literature

• Engagement of nursing leadership

• Creation of terms of reference

• Knowledge of the level of professionalism and confidentiality required by all

• Development of the process for review and presentation

Creating the Supporting Argument


Terms of Reference

• To create a collegial environment to discuss adverse events focused on system quality and not individual performance

• To promote transparency and engagement to discuss case studies within the domain of nursing Indictors

• To identify if best practices were implemented

• To determine if the adverse event was preventable for the purposes of quality improvement only

• To allow an opportunity to identify gaps in systems and explore opportunities to improve care (Zavotsky et al, 2018; Guger et al, 2011)

• Heart and Vascular Program Director

• Unit CLM

• Heart and Vascular Nurse Educator

• Staff Nurses

• Vascular Surgery Nurse Practitioner

Terms of Reference‐Attendees

Terms of Reference ‐Process

• Nurse educator reviewed the IAT adverse event with staff RN that completed the IAT event

• Nurse Educator and NP reviewed best practices/protocols/procedures associated with this event with RN

• NP provided guidance to RN in how to review the steps leading to the event and objectively present the event

• NP supported RN in her reflective practice during preparation for presentation. Reviewed best practices and if/how this event was preventable (Zavotsky et al, 2018; Guger et al, 2011)

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Rules of Engagement• Blame free‐encourage openness, honesty and

transparency

• Focus of improvement of systems and processes not on individual performance

• Systems approach to discussion and analysis‐London analysis

• Recommendations only are recorded

• NO discussion outside the meeting room


The Analysis

• Human factors ‐understanding the variance in supporting Vascular Surgery and CV surgery patients post‐op

• Systems factors ‐was task‐based –more attention to vital signs after bolus and his poor response to bolus

• Patient factors ‐Hypotension in post‐op Vascular Surgery patients

(Vincent et al,2004; Health Improvement Scotland (2016)

Factor Types Contributory Influencing Factor

Patient factors • Condition (complexity and seriousness)• Language and communication • Personality and social factors

Task and technology factors • Task design and clarity of structure• Availability and use of protocols • Availability and accuracy of test results• Decision‐making aids

Individual factors • Knowledge and skills• Competence• Physical and mental health

Team factors • Verbal communication • Written communication • Supervision and seeking help • Team structure (congruence, consistency)

Analysis –the London Approach (sample)


Factor Types Contributory Influencing Factor

Work environmental factors • Staffing levels and skills mix • Workload and shift patterns • Design, availability and maintenance

of equipment • Administrative support environment• Physical

Organizational and management factors • Financial resources and constraints• Policy, standards and goals • Safety culture and priorities

Institutional context factors • Links with external organisations

Analysis –the London Approach (cont’d)


Our 3 Events

• Hypotension in Vascular Surgery patients

• Femoral Access as the route of all evil

• Pressure injury/ulcer risk and prevention in Vascular Surgery

Working on Processes…

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Recurring Themes with Adverse Events

Using effective communication

Benefit of additional education

Improving processes/systems

Ensuring accurate documentation

SBAR‐Tool of Communication

• Situation‐ a brief statement of the problem

• Background‐reason for admission & pertinent history

• Assessment‐focused assessment

• Recommendation – be clear 1. what you want 2. when you want them to come 3. anything for you to do/anyone to consult until they come 4. name and position of who you called

(Shahid, 2018)

SBAR‐Tool of Communication (sample)• Situation‐”Hi Patrick, this is Sue, an RN on 7CCN. I’m calling about Ms. White, in 768‐3 who has no detectable right femoral pulse

• Background. Ms White is 78 admitted with left limb ischemia. She went to IR today to improve blood supply to her left foot. IR used her right groin as access. It was a difficult procedure‐she had a right femoral pulse before she went to IR. She had a previous left ileo femoral bypass.

• Assessment. The right femoral pulse is not detected. Her right foot remains warm and sensorary and motor function are intact.

• Recommendation –The pulse is no longer there and I need you to come now and assess her. Should I send her for an arterial Doppler before you come?

Education• Keeping it short and focused

• 10 minutes in length

• Focus on assessment

• Clarity and brevity in communication

• Reiteration of SBAR

• Brief summary of literature

• Emphasis on improving systems & processes AND documentation

Working on Processes…

• Hypotension in Vascular Surgery patients• Education of nurses• Revision of specific BP parameters in the order sets• Escalation policy specific to Vascular Surgery (timelines

for response and escalation to staff)• Escalation policy laminated and on their WOWs

• Femoral Access as the route of all evil• Education of nurses• Assessment and documentation of both limb perfusion

and access site

• Pressure Ulcer risk and prevention in Vascular Surgery• Education of nurses + revision of kardex• Additional education on legal implication of gaps in

documentation

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References • Canadian Patient Safety Institute. (2016). Hospital Home improvement Resource. Retrieved from https://www.patientsafetyinstitute.ca/en/toolsResources/Hospital‐Harm‐Measure/Documents/Resource‐Library/HHIR%20Pressure%20Ulcer.pdf

• Choudhury, M. (2017). Postoperative Management of Vascular Surgery Patients: A Brief Review, Clinics in Surgery, 2, 1584 retrieved from http://www.clinicsinsurgery.com/pdfs_folder/cis‐v2‐id1584.pdf

• Devereaux, PJ, Sessler, DI . Cardiac complications in patients undergoing major noncardiac surgery. N Engl J Med 2015; 373:2258–69• Guger C, Daum S, Vacek L, et al. (2011). Nursing morbidity and mortality conferences. Journal for Nurses in Staff Development, 27(1): 35–38.• Gupta, P., Gupta, H., Sundaram, A., Kaushik, M., Fang, X., Miller, W., Esterbrooks, D., Hunter, C., Pipinos, I., Johanning, J., Lynch, T., Forse, RA, Mohiuddin, S., Mooss, A.. (2011). Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation, 124,381–7

• Health Improvement Scotland (2016).Draft Practice Guide for Mortality and Morbidity Meetings , retrieved from www.healthcareimprovementscotland.org

• Irani, F., Kumar, S & Colyer, W.. (2009). Common femoral artery access techniques: a review. Journal of Cardiovascular Medicine , 10 (7), 517‐22.• Lonjaret L, Lairez O, Minville V, Geeraerts T. 2014. Optimal perioperative management of arterial blood pressure, retrieved from https://www.dovepress.com/optimal‐perioperative‐management‐of‐arterial‐blood‐pressure‐peer‐reviewed‐fulltext‐article‐IBPC

• Ministry of Health and Long Term Care, 2016. Quality of Care Information Protection Act http://www.health.gov.on.ca/en/common/legislation/qcipa/• Morris, John. (2011). Law for Canadian Health Care Administrators, 2nd ed (LexisNexis Canada Inc.,) pages 144‐147.• Norton et al. (2017). Best Practice Recommendations for the Prevention and Management of Pressure Injuries. Wound Retrieved from https://www.woundscanada.ca/docman/public/health‐care‐professional/bpr‐workshop/172‐bpr‐prevention‐and‐management‐of‐pressure‐injuries‐2/file

• Pagano L. & Lookinland S. (2006). Nursing morbidity and mortality conferences: promoting clinical excellence. American Journal of Critical Care, 15(1), 78–85.

• Rahul A. Sheth, MD, T. Gregory Walker, MD, Wael E. Saad, MD, Sean R. Dariushnia, MD, Suvranu Ganguli, MD, Mark J. Hogan, MD, Eric J. Hohenwalter, MD, Sanjeeva P. Kalva, MD, Dheeraj K. Rajan, MD, LeAnn S. Stokes, MD, Darryl A. Zuckerman, MD, and Boris Nikolic, MD, MBA, for the Society of Interventional Radiology Standards of Practice Committee . (2014). Quality Improvement Guidelines for Vascular Access and Closure Device Use , Journal of Vascular Interventional Radiology, 25, 73‐84.

• Rajebi, H. & Rajebi, M. (2015). Optimizing Common Femoral Artery, Techniques in Vascular and Interventional Radiology, 18 (2), 76‐81• Rashid, S. & Hughes, S. (2016). Risk factors for femoral arterial complications and management, BrItish Journal of Cardiology, 23,155–8

• Registered Nurses’ Association of Ontario [RNAO]. (2011). Risk Assessment and Prevention of Pressure Ulcers Best Practice Guideline. Retrieved from: http://rnao.ca/bpg/guidelines/risk‐assessment‐and‐prevention‐pressure‐ulcers • Registered Nurses’ Association of Ontario [RNAO]. (2016). Taking the Pressure Off: Preventing & Managing Pressure Injuries. https://rnao.ca/sites/rnao‐ca/files/Health_Education_Fact_Sheet_Pressure_Injury_‐_5_FINAL.pdf• Registered Nurses’ Association of Ontario [RNAO]. (2016). Assessment and Management of Pressure Injuries for the Interprofessional Team . Retrieved from https://rnao.ca/sites/rnao‐ca/files/In_the_Know__PI_BPG_FINAL_Oct_4_2016_‐_TO_POST.pdf• Robertson,L., Andras,A., Colgan, F., Jackson, R. (2016) Vascular closure devices for femoral arterial puncture site haemostasis, Cochrane database of systematic reviews, http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009541.pub2/ful

• Sessler, D.., Meyhoff, C.M.D.,Zimmerman, N.,Mao, G., Leslie, K. Sessler, D., Meyhoff, C., Zimmerman, N., Mao, G., Leslie, K. et al. (2018). Period‐dependent Associations between Hypotension during and for Four Days after Noncardiac Surgery and a Composite of Myocardial Infarction and Death: A Substudy of the POISE‐2 Trial, Anaesthesiology, 128 (2), 317‐327.

• Shahid and Thomas Safety in Health (2018) 4:7 , Situation, Background, Assessment, Recommendation (SBAR) Communication Tool for Handoff in Health Care – A Narrative Review, Safety in Health, retrieved from SBAR%20.pdf

• Shammas et al. (2017). Predictors of common femoral artery access site complications in patients on oral anticoagulants and undergoing a coronary procedure, Therapeutics and Clinical Risk Management, 13, 401–4

• Sheth et al. (2014). Quality Improvement Guidelines for Vascular Access and Closure Device Use, Journal of Vascular and Interventional Radiology, 25, 73‐84.

• VanLier,F., Hoeks, S., Wesdorp,I., Liem,V., Potters,J., Grüne,F., Boersma,H., Stolker, R. (2018). Association between postoperative mean arterial blood pressure and myocardial injury after noncardiac surgery, British Journal of Anaesthesia,120 (1), 77‐83.

• Vincent C. (2004). Analysis of clinical incidents: a window on the system not a search for root causes. Quality and Safety in Health Care, 13(4), 242‐3. • Woodbury, M. G. & Houghton, P. (2004). Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy Wound Management., 50(10), 22‐38.• Zavotsky, K., Ciccarelli, M., Pontieri‐Lewis, V., Royal, S., Russer, E. (2016).Nursing Morbidity and Mortality: The Clinical Nurse Specialist Role in Improving Patient Outcomes. Clinical Nurse Specialist, 30 (3), 167‐71.

References

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Decreasing length of stay while improving patient

outcomes Wendy Bowles Nurse Practitioner

Vascular Surgery, Royal Columbian Hospital

September 2019

Other HAs (not in photo):PHSAFNHA

1.8 M people

38,000 Frist Nations people (32 Bands)

12 Acute Care hospitals (BBY to White Rock to Hope)

Estimates: 61% 18-64 yrs21% 0-17 yrs18% >65 yrs

2018 Estimates: NHA; 300,000 IHA; 750,000 VCH; 800,000 VIHA; 800,000https://www.interiorhealth.ca/AboutUs/QuickFacts/PopulationLocalAreaProfiles/Documents/Interior%20Health%20Authority%20Profile.pdf

FRASER HEALTH STATS: 2018

Vascular Clinic: Limb Preservation Clinic (LPC)

• The 5 year mortality for a person with peripheral arterial disease (PAD) is 50 to 60% with 70% of those resulting in MACE (major adverse cardiovascular events) and that translates into poor outcomes and huge costs

• USA 24 M people have diabetes and 12 M suffer from PAD with $116 billion direct and another $58.3 billion in indirect costs annually.

• PAD & neuropathy comprise 30 % and 24% respectively, of these expenses with the majority associate with diabetic foot ulcers (DFU) and longer lengths of stay in acute care beds

• 60% of non traumatic amputations are related to or occur in patients with diabetes and 80% of these are preceded by a DFU

Vascular Clinic: LPC QI Proposal

• Current state 2016 Royal Columbian Hospital Vascular Unit• ALOS was high 2016 ALOS was 10-20 days• MD Confidence in Home Care Nursing was low• PAD and referrals late prsentations• Emergency was burdened with patients with failing wounds• The wound care on the unit was rudimentary (minimal

debriding, limited use of advance wound care products, minimal access to WOCN)

Vascular Clinic; LPC QI Immediate Aims

Proposal 2016-17 for Vascular Limb Preservation Clinic: • Decreased ALOS for 3N patients at RCH by 25% by Dec.

2017.• Decreased costs associated with amputations and extended ALOS.

• Reduced length of preoperative stay by avoidance of admission.

• ER avoidance.

• Reduce cost of care for those with DFU (diabetic foot ulcer), DFI (diabetic foot infection) and CLI (critical limb ischemia) as related to in-hospital care costs.

• Enhance the patient experience of care.

• Enhance the provider experience of care.

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Vascular Clinic: : LPC QI Future Aims

Future/ Long Term Outcomes: • Increased awareness of diagnosis criteria for PAD by at least 50% of

practicing primary care providers in Fraser Health Authority initially and all Health Authorities within British Columbia.

• Reduction of major amputation rates trending within Health Authority by 15% at year one.

• Reduce per capita cost of care for those with Diabetes, DFU (diabetic foot ulcer), DFI (diabetic foot infection) and CLI (critical limb ischemia) as related to time to heal.

Vascular Clinic: LPC QI Project

•What changed?• Length of stay went down on average 1.5 days

(ALOS 6-13 2019)• ER congestion limited: 44 ER avoidances in 2017 and over

27 in 2018• Direct admits to 3N; rapid access to ID and ENDO

consultations • Rapid access to Vascular Consults for other services• Decreased use of Home Care services (*data lacking)• Improved patient experience• Improved provider experience

Vascular Clinic: Vascular Lab (VL)

• There exists a population of patients that are under recognized, who are receiving fragmented and substandard care with regard to early disease recognition and access to appropriate and timely treatment of PAD including limb threatening conditions

• Early PAD recognition leads to less expensive and more appropriate care thereby avoiding ER visits, expensive diagnostics and treatments and improved limb salvage rates which is associated with cost savings .

Vascular Clinic: Vascular Lab (VL) QI Proposal

• Proposal for Vascular Lab 2017-18• 2017 Current wait list for vascular studies in Lower Mainland/Fraser Valley

approximately 12 months

• Only accredited VLs (2) are in Vancouver Coastal Health; none exist in FHA*

• Patients with in FHA either do not have access or have delayed access to appropriate diagnostics for assessment of PAD

*NHA, IHA and VIHA are not included here

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Other HAs (not in photo):PHSAFNHA

1.8 M people

38,000 Frist Nations people (32 Bands)

12 Acute Care hospitals (BBY to White Rock to Hope)

Estimates: 61% 18-64 yrs21% 0-17 yrs18% >65 yrs

2018 Estimates: NHA; 300,000 IHA; 750,000 VCH; 800,000 VIHA; 800,000https://www.interiorhealth.ca/AboutUs/QuickFacts/PopulationLocalAreaProfiles/Documents/Interior%20Health%20Authority%20Profile.pdf

FRASER HEALTH STATS: 2018

Vascular Clinic: Vascular Lab (VL) QI Proposal

• VL Immediate and Future Aims:• Provide access to non invasive, less expensive diagnostics for assessment of

PAD

• To decrease the number of diagnostic CTs for assessing presence of PAD by 10% by September 2018

• To improve and increase early detection of PAD in FHA.

FALCON PRO DIAGNOSTIC SYSTEM

Vascular Clinic: VL QI Project

•What changed?Patients seen in VL:

• 2017: 186 (Sept-Dec)

• 2018: 1,120

• 2019: 997 (Jan-Sept 6*)

Wait times:

• 2018: Urgent within 1 week; non urgent 1 month

• 2019: Urgent within 1 week; non urgent 1.5-2 months

• CTs ordered have not decreased for low prescribers**

*123 difference to 2018 with 3/12 to go. **Data analysis in process

Vascular Clinic: LPC and VL

• What do the staff and providers say?• Improved satisfaction of vascular physicians; better access for their patients,

improved wound care compared with Home Care alone, more confidence• Nurses on 3N benefit love access to WOCN• Better advocacy for patients with services• Family physicians/ community RNs can call and discuss

with NP or WOCN any issues • Community providers: family docs, Cardiologists, ID, Endocrinologists appreciate rapid access to vascular diagnostics

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Vascular Clinic: LPC and VL

• What do the patients and families say?• Love the continuity of care and familiar faces• Eliminating Home Care for wounds and finding improved outcomes • Appreciate not having to go to ER• Appreciate faster access to VL

Vascular Clinic: future plans

• LIMB PRESERVATION CLINIC• HIRE 2nd WOCN• HIRE LPN/RN ASSIST

• VASCULAR LAB• HIRE RVT • ULTRASOUND• HIRE MOA SUPPORT• EXPAND HOURS

• NEW BUILD PROJECT• Where will the Vascular Clinic be?

VASCULAR LAB

LIMB PRESERVATION CLINIC

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LIMB PRESERVATION: A CASE STUDY

PHOEBE JOY CHOMETA

Disclosure


▸ There are no conflicts of interest

▸Products mentioned in this case study is not for promotion of sales, it is for educational purposes only

The Vascular Surgery Unit of Saint Paul’s Hospital in Saskatoon review a Limb Preservation case study, using our multidisciplinary team of health care professionals and specialized wound care, including Negative Pressure Wound Therapy (NPWT). The process of using a methodology of multidisciplinary collaboration and individualization of wound care forms our objective. Wound care has advanced significantly in recent years (Rehm, 2011) and NPWT has become a pillar of wound care management in the vascular patient population (Acosta, Bjorck, & Wanhainen, 2017). This is a success story, presenting an approach that objectively works. The subject of this case study is RC, who was at significant risk of imminent limb loss secondary to soft tissue infection. The presentation of RC’s inpatient stay trajectory reviews multiple wound care modalities as well as the multidisciplinary team methodology over the course of months.

References

Acosta, S., Bjorck, M., & Wanhainen, A. (2017). Negative‐pressure wound therapy for prevention and treatment of surgical‐site infections after vascular surgery. British Journal of Surgery, 104(2),e75‐e84.

Rehm, K. B. (2011). Beyond wound care: here's a look at the burgeoning field of limb preservation and a salvage (wound management). Podiatry Management, 30(6), 149.

WHAT IS THIS PRESENTATION ALL ABOUT?


▸ This is a case study told in point form

▸ It chronicles a success story

▸ The success is due to a multi collaborative team effort

▸After the case study, we have numerous slides documenting the progression of the wound, to its final state

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LET’S MEET THE TEAM

Nursing

Physical Therapy

Occupational Therapy

Dietician

Medicine (Vascular,Plastics,Critical Care,ID,Nephrology,Opthamology)

Pharmacy

Clinical Psychology

Social Work

Wound Resource Team

Respiratory Therapy

Speech Language Pathology


▸524 hospitalizations for diabetic foot wounds, with over 8000 total days in hospital

▸173 lower leg amputations for diabetic foot wounds

▸Population of Saskatchewan is 1.162 million

▸ Saskatoon is the primary home of Vascular Surgery

2016 ‐ 2017 Statistics for Saskatchewan


▸ 72 year old male

▸Diabetes Mellitus ‐ last A1c 10.6%

▸ Coronary Artery Disease

▸Atrial Fibrillation

▸ Previous CVA ‐ 2016 ‐ No neurological deficits

▸ CABG

▸Appendectomy

▸ Toe Amputation

▸Quit smoking 30 years ago

RC ‐ History

“When Chuck Norris steps on a nail,

The nail gets a tetanus shot”


▸May 15 ‐ Stepped on a nail, went to local hospital for a tetanus shot

▸May 19 ‐ Admitted to local hospital for treatment for sepsis

▸May 26 ‐ Transferred to SPH‐ER for Vascular Surgeon consult, worsening hemodynamics and respiratory status, and for aggressive fluid resuscitation.

▸May 26 ‐ Vascular Surgery brings in ICU and Nephrology, and Infectious Diseases consultations. RC is admitted to observation unit. Intermittent Hemodialysis Initiated

Storyline

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▸May 27 ‐ Pharmacy involved in optimizing medications and appropriate antibiotic coverage

▸May 27 ‐ Physical Therapy consulted. Unable to do due to altered LOC and hemodynamics, DB&C, and following

▸May 29 ‐ Outreach called (Rapid Response Team) for worsening respiratory status, and hemodynamics. RC taken to OR for (R)TMA and medial/lateral (R) fasciotomies. To ICU postoperatively for Vasopressors, CRRT, and Ventilator management. Respiratory Therapy for airway management involved

▸May 29 ‐ Cardiac Rhythm management in ICU (SVT)

Storyline


▸May 29 ‐ Social Work in contact with family/patient and Goals of Care established with Attending Physician and patient (DNR). Dietician consulted to optimize nutrition . Tube feeding initiated

▸ June 1 ‐ Deep wound cultures from surgery grow 2 species of Staphylococcus (simulans and haemolyticus). Toxic Shock Syndrome confirmed ‐> IVIG added into regimen

▸ June 3 ‐ Extubated to Non‐Invasive Ventilation

▸ June 4 ‐ Delirium evident, mobility by Nursing and Physical Therapy initiated

▸ June 6 ‐ Vascular Surgery reviews (R) foot, for concerns from ICU for source control. Angiogram normal. Bedside doppler to right leg shows good flow to right ankle, and foot. The foot deemed viable. Long term prognosis for the foot is uncertain. No amputation planned.

Storyline


▸ June 6 ‐ Serum creatinine plateau’s, no further need for dialysis

▸ June 7 ‐ Transferred out of ICU to 5A Observation

▸ June 8 ‐ RC unable to manage swallowing effectively. Speech Language Pathology consulted

▸ June 8 ‐ Wound Resource Team (WRT) consulted to initiate NPWT to medial and lateral fasciotomies for high fluid drainage and also to prevent maceration of adjacent wound areas. Silver antimicrobial barrier dressing applied to other open areas around TMA

▸ June 11 ‐ Mobility upgraded to activity as tolerated but NWB on (R) foot. Physical Therapy more aggressive with mobility. Occupational therapy consulted

Storyline


▸ June 12 ‐ Modified Barium Swallow completed. RC able to safely progress to eating minced diet

▸ June 15 ‐ Added one more NPWT to the open areas on TMA/foot/leg, as well as the fasciotomies

▸ June 18 ‐ Social work assists RC in applying for disability

▸ June 19 ‐ RC reports substantial visual loss, Ophthalmology consulted. Determined to be bilateral ischemic optic neuritis from Hypotension

▸ June 19 ‐ Clinical Psychology consulted for anxiety and adjustment

Storyline


▸ June 20 ‐ Orthotist in to fit for shoes for offloading

▸ June 21 ‐ Wound bed 100% yellow with dimly adherent slough, conservative sharps debridement done at bedside per Wound Resource Team

▸ July 3 ‐ Small amount of pink granulation tissue appearing. More sharp debridement of slough done at bedside by Wound Resource Team

▸ July 5 ‐ Discontinue the NPWT to the foot wounds due to regression of yellow slough. Keep the NPWT to the fasciotomies

Storyline


▸ July 5 ‐ Occupational Therapy consulted to assist with overseeing activities of daily living

▸ July 18 ‐ To OR for surgical debridement

▸ July 20 ‐ restarted the second NPWT. Wounds 80% pink, and 20% yellow. Fasciotomies nearly closed

▸ July 25 ‐ Transitioned to a NPWTwith instillation system

▸Aug 21 ‐ Surgeon debulked necrosis of tendon at bedside

▸Aug 31 ‐ Deterioration of spouse’s condition. More focus applied to having his needs met at the local hospital close to his home

Storyline

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▸ Sept 4 ‐ Fasciotomies closed. 90% of wounds red

▸ Sept 5 ‐ To OR for STSG with NPWT placement over the grafts for 5 days (Plastic Surgery)

▸ Sept 10 ‐ NPWT removed, 95% STSG take. Bactigras applied with Coban lite compression dressing

▸ Sept 26 ‐ Measured for custom hosiery, for 20‐30mmHg

▸Oct 2 ‐ Transferred to local hospital, to be closer to spouse

Storyline

LIMB PRESERVATION: A CASE STUDY ‐ PICTORIAL STORYLINE

▸Medial Fasciotomy ‐ June 21


▸ Lateral Fasciotomy ‐ June 21


▸ July 5


▸ July 5


▸ July 9

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▸ July 12


▸ July 12


▸ July 16


▸ July 16


▸ July 23


▸ July 23

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▸August 8


▸August 14


▸August 14


▸August 21


▸August 21


▸August 24

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▸August 24


▸ September 4


▸ September 4


▸ September 12


▸ September 12


▸ September 21

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▸ September 28


▸ September 28

IN SUMMARY


▸ There were different modes of NPWT used, depending on the needs of the wound(s)


▸During initial assessment of the patient by Vascular Surgery, of course the question of amputation was raised, in order to save his life

▸ Vascular Surgery’s initial view is that they try to save every leg

▸ Vascular Surgery watched the leg daily to answer the question of amputation or not

▸ ICU again raised the question of amputation; Vascular Surgery felt all of the septic areas on the leg were drained/excised, and the foot was definitely salvageable

▸Upon reflection on all of this, you need a group of people with patience and dedication to review the leg daily, to do major wound care, to support him in areas that the patient will require to leave the hospital, in essence, you need a dedicated team


▸ It takes an entire village to save a limb

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THE END

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Study of the Efficacy of a Removable Rigid Dressing Under Vacuum as a

Post-Amputation Tibial Bandage Modality

Introduction

My professional path

1997

Emergency room nurse

Clinical research nurse (Vascular Medicine department)

2012 2019...

Study of the Efficacy of Removable Rigid Dressing Under Vacuum as a Post-Amputation Tibial Bandage Modality

Issues: Amputation is a treatment of last resort in cases of severe trauma to a

limb or chronic diseases that incapacitate a segment of the body (vasculardiseases, cancer, diabetes, etc.)

Between 1996 and 2004, 15,992 amputations occurred in 10,450 peoplein Quebec.

In its first year, it is estimated that an amputee will incur costs around

$ 48,000, including:

• Admission to hospital• Care• Related complications

• Drugs• Home care and long-term care• Considering rehabilitation


Necrotic ulcers, stage IV ischemia, diabetic foot ulcers


Issues: Subsequently, the amputated patient goes through a pre-molding

period of 8 to 10 weeks before obtaining his final prosthesis. Thisperiod allows: stabilization of the stump where he will receive nursing care (wound

control and bandages)

rehabilitation (walking training with temporary prosthesis and control ofedema)

The main variable determining the moment of molding of thedefinitive prosthesis is the stability of the stump size, which variesaccording to the edema, followed by the complete healing of thewound.


soft dressing (SD)

plaster (RD)removable rigid dressing (RRD)

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Issues: Studies tend to show:

a longer appliance time with SD and less edema control than othermodalities.

RRD has a better effectiveness in terms of decreased pre-device timeand associated complications with respect to RD and IPOP (Immediate

postoperative prosthesis)

In spite of its more advantageous efficiency, the RRD remains amoderated modulus little used in Canada, particularly in Quebec,where no comparative study has been recorded compared to theusual methods.


Removable rigid dressing (RRD)


Literature reviews:

Etiology of amputation

Quebec is currently experiencing an aging population:

One in six men (1/6) and one in seven (1/7) women aged 55 and overwere diagnosed with diabetes in Canada in 2008

Knowing that between 2015 and 2016, the population of Quebec hasexpanded by about 50,000, the number of people with diabetes will onlyincrease.


Literature reviews:Etiology of amputation

Diabetes accounts for 70% of non-traumatic lower extremity amputations in Canada, with a prevalence of 49.6 amputations per 100,000 people with the disease.


Literature reviews:

Etiology of amputation

People with diabetes are about 20 times more likely to havelower limb amputations compared to the normal population

Between 1996 and 2004, 15,992 amputations were performedin Quebec 83.6% of this number had a vascular origin, which could be due

to diabetes, or to another vascular disease, which in 2007affected nearly 1.3 million Canadians.


Literature reviews:

Period of hospitalization after amputation

Trans-tibial amputation is a surgery

consisting of resection of a variable portion

of the tibia and fibula to obtain a flap scar

which can be then placed in the anterior or

posterior side of the residual limb

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Literature reviews:Period of hospitalization after amputation

Other expenses also arise from the rehabilitation process in which amputees navigate, including: Acclimatize to the wearing of a prosthesis

Recovery of functional abilities

The recovery includes: Prevention of contractures

Mobility and desensitization of the stump

Muscle strength of the affected limb

General autonomy of the patient


Literature reviews:The means of compression of edema

Removable semi-rigid dressing Removable rigid dressing (RRD)

Elastic bandage Compression stocking (SD) (SD)

non-removable hard dressing (RD)


The means of compression of edema

Literature reviews:

PPAM IPOP

Pneumatic Post Amputation Mobility Immediate Post Op Prosthesis



Elastic bandage is the most commonly used edema restraint because ofits accessibility to the wound, though it has been shown to be neitherreliable nor adequate in terms of applied pressure and pressuredistribution

The average time before molding the first

prosthesis is 84 to 110 days



At the level of the rigid and semi-rigid dressing, the recommendationrating is B, with a mean time before molding of the first prosthesisbeing quite similar between the two types 34 days for the plaster

37 days for the semi-rigid removable dressing, which includes theÖssur Rigid Dressing (ORD).


Literature reviews:Conclusion

Amputation is part of the reality for people with vascular disease anddiabetes, but current methods of controlling edema and woundmanagement at the stump are now largely based on an old-fashionedbasis and considered ineffective by the still very present use of theelastic bandage.

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Methodology

The specific objectives are:

1. Explore the effectiveness of RRD compared to the E-band for the stabilization of stump size, associated complications, and the time needed to cast the prosthesis.

2. Verify facilitators and barriers to RRD implantation as a post-amputation tibial dressing modality as an alternative to elastic bandage.


Methodology

Research device:

The research design of this pilot study will be a randomized clinical trial (RCT). Participants will be randomly randomized, unblinded experimental group (RRD ORD)

control group (usual treatment: elastic bandage).

Evaluated every day from the time between surgery and discharge from the hospital.

Every week until the prosthesis is cast.


Methodology

The inclusion criteria: 1. Require trans-tibial amputation of non-traumatic cause

2. Be aged between 40 and 75 years

3. Be able to give free and informed consent

The exclusion criteria: 1. Presenting a medical condition that can influence significantly the

healing of the stump

2. Demonstrating an inability to cooperate with the rehabilitation protocol


Recruitment procedures

Eligible patients will be identified by the vascular surgeon

Have a face-to-face meeting before surgery, to sign the consent form and be randomized to a group


Procedures for data collection

Objective 1

For both groups

1. verify the stability of the stump size (edema)

2. the associated complications (redness, edema, dryness)

3. the time required before molding the prosthesis

The measurement times and the data collected will be the sameregardless of the home group.



Project timeline

RANDOMISATIONData collection (D0)

D1

Measurements of the stump every day

Usual dressing

ORD

Am

pu

tati

on

Hospitalisation

D2

D3

D4

-…

Dx

Ho

spit

al

leav

e

W1

Measurements of the stump every week

Rehabilitation

W2

W3

W4

...

Wx

Prosthetic fitting

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Objective 2

Verify facilitators and barriers to RRD implementation as a post-amputation tibial dressing modality as an alternative to elastic bandage.

Collect, through a semi-structured interview, comments from the surgeon, physiotherapist, research nurse and the participant.


SAMPLE SIZE AND DATA ANALYSIS

Ten participants will be recruited in this pilot study,

five for the control group (elastic bandage)

five for the experimental group (ORD)

This sample size is considered sufficient to have a first estimate of the differences between the usual treatment and the ORD.

The data from both groups will be compared with appropriate non-parametric statistical tests.

Interview data collected will be used to identify barriers and facilitators of the use of the ORD.


RELEVANCE OF THE RESULTS OF THE STUDY The results of this study will be used to provide preliminary data

for Quebec regarding recommended level B compressive modality (ORD)

elastic bandage recommendation level D according to BACPAR.

This will guide the relevance of conducting a subsequent larger study. The ORD would reduce: rehabilitation time compared to the elastic bandage which, in the

end, would reduce the direct and indirect costs of amputation for the Quebec health system.


Principal Investigator and author: Pr Michel Tousignant, PT, Ph.D. Full Professor,

Université de Sherbrooke, Research Center On aging

Co-investigators: Dr Marc-Antoine Despatis, CIUSSS of Estrie-CHUS, FMSS, CRCHUS

Vascular Surgeon

Dr Ghislain Nourissat, CHU of Quebec, Vascular Surgeon

Dominique Bisson, CIUSSS of Estrie-CHUS, Rehabilitation Therapist

Dr Ariane Rajotte-Martel, CIUSSS National Capital, Physiotherapist

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Thursday, September 12, 2019

0730-0830 Breakfast0830-1010 Vascular Potpourri

0830-0900 Delirium: The role of cognitive impairment and type of vascular surgery procedure, Rima Styra MD

0900-0930 KeyNote Speaker- ACST-1 and ACST-2, the largest carotid trials in the world - What can we learn and why do large trials matter so much?Professor Alison Halliday

0930-1000 Your’re so vein: Modern management of varicose veins, April Boyd MD


1010-1050 Break/ Exhibitors

1050-1210 Vascular Nursing: Future Directions and Opportunities

1050-1110 Negative pressure wound therapy - welcome to the jungle of wound care, Michelle Fleur de Lys RN

1110-1130 Oh, the places you’ll go: Nursing, vascular surgery, and artificial intelligence,Sharon McGonigle NP


1140-1200 Panel Discussion – Vascular Education: An Interactive Nationwide Discussion- Manager: Dorina Baston RN- Clinical Educator: Deedee Kian RN- Staff Nurse, Hilary Doucet RN


1210-12401240-1310

1310-1320

LunchLunch Symposium- The Compass Trial, Thomas Lindsay MD, Bertha Hughes NPSponsored by Bayer Inc.Panel/Questions

1320-1550 Aneurysms and Endograft Procedures

1320-1350 “Einstein to EVAR” The evolution of abdominal aortic aneurysm surgery, Kirk Lawlor MD

1350-1410 EVAR infections: A clinical vignette, Amanda Stuhldreier RN

1410-1430 Journey back to life; Complex TEVAR, Alex Keks RN

1430-1440 Panel/ Questions

1440-1450 Break

1450-1510 The patient experience around connecting the dots: Mycobacterial graft infection and BCG bladder treatment, Hilary Doucet RN

1510-1540 Not what the doctor ordered: Vascular graft infection and its management, Gary K Yang MD

1540-1550 Panel/ Questions

1550-1600 Closing Remarks

1730-? Optional Event- Summerhill Wine tasting and Buffett dinner. (Transportation on your own)

2019‐09‐22

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RIMA STYRA MD, MED

CSVN, 2019

Delirium: The role of cognitive impairment and type of vascular surgery procedure

Objectives

• Review rationale for the study

• Identify usable risk factors pre-operatively

• Examine the impact on patient and hospital resources related to cognitive impairment and delirium

• Discuss possible options to optimize care

Vascular Surgery Patient Scenario

• 83 yo married male, accompanied to the surgeon’s office by wife and daughter

• Daughter presents the history, questions directed to the patient are deferred to the daughter

• Patient is pleasant, smiles, cooperative

• Elective surgery arranged

Post-op• Patient found to be confused, CAM positive, delirium likely

cause

• Workup by team and projected length of stay increases from 3 days to 3 weeks to….

• Patient continues to be confused, team continues to work hard to identify an etiology

• Sitter required due to confusion and risk of falls, increased agitation at night

• Long term discharge planning begins

Delirium rates in postoperative vascular patients have been reported to range from 5% to 39%

Similar variability in cardiac population – 6% - 50.6%

Highest incidence in vascular surgery abdominal aortic surgery - 46-52%

Intensive Care Units (ICU) populations in general

40-87%

Introduction and Study Rationale

Introduction and Study Rationale

Delirium increases perioperative morbidity and mortality

Delirium prolongs the patient’s length of stay and impacts recovery

Delirium duration has been found to be associated with length of stay even after adjustments for illness severity and age

Delirium accelerates cognitive decline in patients with pre-existing cognitive impairment resulting in a new functional baseline

Patient and family are often surprised and disappointed with outcome

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Older vascular surgery patients

• Older patients benefit from vascular surgery but they remain at higher risk than younger patients of adverse outcomes1

• With an aging population, more octogenerians are undergoing surgery2

• Vascular patients are already vulnerable given the risk of CVA and repeated TIA incidents, which result in mild cognitive impairment (MCI) 3

• Interestingly minimally invasive surgery does not impact upon complication rates of endovascular procedures in those patient with age >75 4

1 Jim, Annals Vasc Surg 20102 Cudennec, Annals Vasc Surg 2014

3 O’Brien, Lancet, 20034 O’Brien,Ir J Med Sci, 2012

Prospective preoperative screening of 173 vascular patients scheduled for Vascular surgical procedures

• MoCA (Montreal Cognitive Assessment) Tool pre-operatively

• CAM/CAM-ICU and clinical review for diagnosis of delirium post-operatively

Retrospective chart review of an additional 434 vascular patients (elective and emergency surgery patients) toassess the cost impact of delirium and dementia

Sitter needs (days) were categorized based on three categories:

• Delirium

• Dementia and delirium

• Dementia only

Study Overview

MOCA Tool Worksheet

Normal range: 26 -30

Cognitive impairment (vascular patients):< 24

Dementia (moderate/severe):≤ 15

MoCA• Detects 90% of mild cognitive impairment

• Patients with mild Alzheirmer’s Disease 100% detection, 87% specificity

• High retest reliability

• Validated in cerebrovascular disease

• A strong relationship of impairment on the MoCA independent of age was shown with cognitive impairment of vascular etiology

• Cut off of <24 established in vascular disease

Data Total sampleN = 173

(100%) (SD)

PODN = 20

(11.6%) (SD)

Non-PodN = 153

(88.4%) (SD)

P

Gender (males) 127 (73.4%) 16 (11.7%) 121 (88.3%) 0.59

Age 69.9 + 10.97 71.9 + 8.22 69.7 + 11.28 0.40

Age >70 78 (45.1%) 8 (10.3%) 70 (89.4%) 0.41

Previous delirium 36 (21.8%) 8 (22.2%) 28 (77.8%) 0.03b

Depression 9 (5.2%) 2 (22.2%) 7 (77.8%) 0.28

CVA/TIA 40 (23.1%) 8 (20.0%) 32 (80.0%) 0.06

Opioids 34 (19.6%) 4 (11.7%) 30 (88.3%) 0.58

Illicit Drugs 7 (4.0%) 1 (14.3%) 6 (85.7%) 0.58

Psychotropic Medication 47 (27.2%) 9 (19.1%) 38 (80.9%) 0.06

Heavy alcohol use 14 (8.0%) 2 (14.3%) 12 (85.7%) 0.26

Total MoCA Score 23.5 + 4.21 21.2 + 6.07 23.7 + 3.83 0.01a

MoCA <24 119 (68.8%) 11 (9.2%) 108 (90.8%) 0.95

Dementia (pre-existing) 9 (5.1%) 4 (44.4%) 5 (55.6%) 0.00a

Preoperative Patient Characteristics for those with Post Operative Delirium (POD) and without non-POD

a Indicates significance level of p <.01b Indicates significance level of p < .05 Univariate Analysis

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Delirium rates by Age

• 80-89 years - 16.6%

• 70-79 years – 11.8%

• 60-69 years – 14.9%

• 50-59 years – 6.3%

• <50 and ≥ 90 – 0%

• No significant differences between cohorts ≥70 and <70 years of age

Preoperative Patient Characteristics for those with Post Operative Delirium (POD) and without non-POD (continued)

Data Total sampleN = 173

(100%) (SD)

PODN = 20

(11.6%) (SD)

Non-PODN = 153

(88.4%) (SD)

P

Lower limb amputation 8 (4.6%) 5 (62.5%) 3 (37.5%) 0.00a

Open aortic surgery 25 (14.4%) 8 (32.0%) 17 (68.0%) 0.00a

Carotid surgery 20 (11.5%) 0 (0%) 20 (100%) -

EVAR 75 (43.4%) 7 (9.3%) 68 (90.7%) 0.29

Femoral/Infra Inguinal surgery

35 (20.1%) 0 (0%) 35 (100%) -

Angioplasty alone 1 (0.57%) 0 (0%) 1 (100%) -

Other surgery 9 (5.2%) 0 (0%) 9 (100%) -

a Indicates significance level of p <.01

Incidence of POD by Vascular Surgery Procedure

Surgery type MoCAVisuospatial/Executive

M + SD

MoCAMemory

M + SD M + SD

MoCATotal

Scores

PP

All surgery types 4.1 + 1.01 2.1 + 1.63 23.5 + 4.12 .002a -

Lower limb amputation

3.9 + 1.07 2.7 + 1.98 17.0 + 5.74 .000a -

Open aortic surgery 4.1 + 1.16 2.4 + 1.94 23.7 + 4.68 .747 .001b

Carotid surgery 3.7 + 1.08 1.8 + 1.58 23.3 + 3.59 .971 .006c

EVAR surgery 4.1 + 0.97 2.1 + 1.46 23.7 + 3.71 .366 .000b

Femoral/Infra Inguinal 4.2 + 0.81 2.2 + 1.71 23.9 + 3.77 .484 .001b

Other surgeries 3.8 + 1.39 1.6 + 1.59 24.1 + 3.02 .339 .006c

MoCA scores by vascular surgery procedure with further analysis of the visuospatial/executive and memory domains in the lower limb amputation group

a Indicates significance level of p <.01 for MANOVA with all surgery typesb Indicates significance level of p < .01 for Tukey test with lower limb amputation c Indicates significance level of p <.05 for Tukey test with lower limb amputation

Variable OR 95% CI P

Lower LimbAmputation

16.67 3.14 – 71.54 0.00a

Open aortic surgery 5.33 1.91 – 14.89 0.00a

Dementia (pre-existing)

5.63 2.08 – 15.01 0.00a

MoCA score (<15) 6.13 1.56 – 24.02 0.02b

Previous delirium 2.98 1.11 – 7.96 0.03b

Predictive Variables for POD Multivariate logistic regression analysis

a Indicates significance level of p < .01b Indicates significance level of p < .05

Independent Odds Ratios of Previous Vascular Delirium Studies

Study Aetiological factors Odds Ratio CI of odds ratio P value

Katznelson 2009 Aortic reconstruction 5.34 2.54-11.2 <0.001

(N=582 Chart review) Amputation 4.66 1.96‐11.09 <0.001

Preoperative depression 3.56 1.53-8.28 0.003

History of CVA/TIA 2.64 1.57-4.45 <0.001

Age 1.04 1.02-1.07 <0.001

Patient group N = 434(100%)

PODn = 90

(20.7%)

Non-PODn = 344 (79.2%)

P

Emergency 44 20 (45.5%) 24 (54.4%) .005a

Elective 390 70 (17.8%) 320 (82.1%) .000a

Dementia 25 18 (72.0%) 7 (38.9%) .001a

Non-dementia 409 72 (17.6%) 337 (82.4%) .000a

Incidence of POD and Dementia in the Retrospective Vascular Surgery Cohort


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Patient group N = 434(100%)

% of totalunit sitter

days

Mean (Days per patient)

Range(Days per patient)

Delirium alone 72 (16.6) 51% 3.9 <1 – 30

Delirium with dementia

18 (4.1) 48% 13.6 1 – 44.8

Dementia alone 7 (1.6) <0.0001% <1 0.5 – 5.2

Sitter Days per Cohort


0

10

20

30

40

50

60

70

>24 25-99 100-999 >1000

Delirium alone

Delirium with Dementia

Range of Sitter Hours for POD (Post Operative Delirium) with and without Dementia

Number of sitter hours

Per

cent

ages

of

delir

ious

pat

ien

ts

Limitations

• Prospective study: was unable to include emergency urgent patients

• Retrospective study: Chart review was only able to identify cognitive status into two categories dementia or non-dementia

Preoperative MoCA screening can identify high risk patients for POD, by recognizing significant pre-operative cognitive impairment that may not be apparent clinically without testing

Identification of high risk patients can lead to:• potential procedure modification• education of the patient and family regarding POD risk• implementation of preventative strategies

Patients with dementia and POD account for the majority of cost associated with sitter needs

Identification pre-operatively of a small number of patients in our center could have resulted in substantial savings (sitter needs)

Conclusions

Optimizing Perioperative Care of Older Patients

• Treatment concept needs to include the entire perioperative phase as a seamless continuum of care

• Optimization of procedural pathways in the hospital –assessment of cognitive function pre-surgery as opposed to when concerns arise

• Interdisciplinary collaboration

• Risk assessment informs the patient and family regarding their risk, as part of the process of informed patient consent

Olutu, Dtsh Arztebl Int, 2019

Tomlinson,Perioperative Med, 2016

• Thomas F. Lindsay

• Dorina Baston

• Jeanne Elgie-Watson

• Linda Flockhart

• Michelle Dimas

• Elisabeth Larsen

Funding: Peter Munk Cardiac Centre Innovation Fund

Acknowledgements

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Journal of Vascular Surgery Jan 2019, 69(1) 201-209

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Nursing, Vascular Surgery and Artificial Intelligence

Sharon McGonigle, RN, MScN, NP-Adult

Dr. Seuss

Objectives:

• Demystify Artificial Intelligence

• Understand the language of the AI market place

• AI in health care:

–Nursing

–Vascular Surgery

What’s in a name?

Hammond, Kristian (2015)

What’s AI?

• No common definition

• Computer systems able to perform tasks that usually require human intelligence

Definition: English Oxford Dictionary (2018)

What’s involved in Intelligence?

• Ability to interact with the world (speech, vision, motion, manipulation)

• Ability to model the world and to reasonabout it

• Ability to learn and to adapt

Hammond, Kristian (2015)

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Roots of AI

Russell and Norvig (2019)

The Goal of AI

• To understand intelligence in order to model it

• To build systems that exhibit intelligent behavior

Nomenclature of AI

• Big Data – extremely large data sets that are analyzed to

reveal patterns, trends and unique associations related to human interactions and behaviors.

• Machine Learning– the design of learning algorithms to analyze “Big

Data” sets, learn from it and then determine or predict a set of events.

– learns from experience and improves performance as it learns

Nomenclature of AI

• Deep Learning via

• Deep Neural Networks

DATA

https://master-iesc-angers.com/artificial-intelligence-machine-learning-and-deep-learning-same-context-different-concepts/

AI in our every day lives

Driverless cars: driven by Deep Learning

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AI and Health Care

What can machine learning do for the health care industry?

Personal health tracking Medical imaging Patient Monitoring

Home monitoring Medication adherence Pathology Quantification Genomics Analytics

Topol, 2019

AI and Healthcare: Patients

AI and Healthcare: Systems

Improve accuracy of diagnosis,

prognosis, and risk prediction.

Improve quality of care and outcomes, while reducing

healthcare costs.

Optimize hospital processes such as

resource allocation and patient flow.

Automate detection of relevant findings in

pathology, radiology, etc.

Identify patient subgroups for

personalized and precision medicine.

AI for Clinicians: VirtualPattern Recognition

AI for Clinicians: PhysicalRobotics

Robear

Paro, the harp seal

Cody

Vascular Surgery: Robotic Assist

• Endovascular Suite

• Robotically steerable catheter within a peripheral blood vessel

• Magellan Robotic system

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Elements of the VCC system

www.hansenmedical.com

Magellan Robot• Magellan Robot

Magellan VCC system

Take Home Messages about AI:• No common definition

• You’re Already Using It

• Will Not Replace Nurses

• Robotics in Vascular not a lot of buy in

• Nurses can help to drive AI’s future

• Dream Big

References1. Carroll, W. (July, 2018). Artificial Intelligence, Nurses and the Quadruple Aim. Online

Journal of Nursing Informatics (OJNI), 22(2). Available at http://www.himss.org/ojni

2. English Oxford Living Dictionary. 2018. Definition: Artificial Intelligence. Retrieved from https://en.oxforddictionaries.com/definition/artificial_intelligence

3. Hammond, Kristian (2015) Practical Artificial Intelligence For Dummies®, Narrative Science Edition. John Wiley & Sons, Inc., Hoboken, New Jersey

4. www.hansenmedical.com.

5. https://master-iesc-angers.com/artificial-intelligence-machine-learning-and-deep-learning-same-context-different-concepts/

6. https://www.nytimes.com/2019/02/24/business/china-pig-technology-facial-recognition.html

7. Rao, Sandeep (2016). Endovascular Robotic Catheters: An Emerging Transformative Technology in the Interventional Radiology Suite. Journal of Radiology Nursing, Volume 35, Issue 3, September, Pages 211-217 https://doi.org/10.1016/j.jradnu.2016.04.022

8. Russell , S. & Norvig, P. (2019) Artificial Intelligence: A Modern Approach (4th Edition). Prentice Hall, New Jersey

9. Topol, E. (2019) High-performance medicine: the convergence of human and artificial intelligence. Nature Medicine, Vol 25, January, p 44-56

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EVAR Infections: A Clinical Vignette

By: Amanda Stuhldreier RN BN, Jean Bernasor RN BN, Julia Javier RN BN

Objectives

- Discuss an EVAR infection and resulting complications.

- Discuss nursing management of patients EVAR infection and goals of care for planned patient discharge.

- Discuss the interdisciplinary health care teams roles regarding patients hospital stay and plans for discharge home.

Background

- History of Present Illness (HPI):

- 75 y/o female- s/p EVAR for AAA 6cm (2012)

- Recurrent fevers, chills, lethargy and night sweats for 2 years

- Long standing po antibiotics for EVAR Graft Infection

- Transferred from community hospital to tertiary care for further investigations & surgery.

Background

PMHx:- CAD - Pulmonary fibrosis- OSA: CPAP, Home O2 - Chronic leg pain (Gabapentin)

- HTN - DM 2- Hypothyroidism (on replacement) - High cholesterol- GERD (on Pantoprazole) - Migraines- Ex-smoker 30/ppy (quit @ age 55) - Sinusitis

Background

PSHx:- Rt CEA Sept, 2004

- CABG x 4 - Sept. 2010

- Lumbar Spine fusion - May, 2012

- EVAR- July 2012

Social Hx:

- Depression and Anxiety

- Lives with brother

- Lives in a bungalow, 3 stairs at entrance

Allergies: Morphine

Background

Blood Cx:

- June 2018: MMSA, + Granulicatella adiacens: ○ WBC scan (suspected source AAA sac and surrounding tissue)

- Aug 2018: CIVP program x 6 weeks: followed by Infectious Diseases (ID)o Ceftriaxone 2gm IV OD

o Stepdown to Septra DS BID life-long.

- Sept 2018: CTA: increased gas in residual aneurysm sac

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EVAR Procedure

- Placement of the prosthetic endograft within the thoracic/abdominal aorta at the site of an aneurysm

- Endograft components are then compressed within a delivery sheath

- Introduced into the vascular system through the lumen of an access vessel (e.g. femoral artery), to be subsequently deployed at the site of aneurysm

- (Daye, D., & Walker, T.G. (2017))https://en.wikipedia.org/wiki/Endovascular_aneurysm_repair#/media/File:Aneurysm_endovascular.jpg

Advantages of EVAR

- Decreased blood loss

- Eliminates need for cross-clamping the aorta

- Associated low perioperative 30-day all-cause mortality (Daye & Walker, 2017)- significant reduction in peri-op morbidity vs. open surgery- shorter recovery period

- Incidence of infection is RARE and LOW resulting in delayed diagnosis (Smeds, et. al, 2016)

Disadvantages of EVAR

- High rate of post-procedural complications:

- Secondary re-intervention

- Patient compliance:- lifelong imaging surveillance after repair

- Radiography, CT, Angio, Ultrasound, MRI and CTA(Daye, D., & Walker, T.G. (2017))

Complications of EVAR

One of the most common causes of endograft infections are bacterial seeding in which bacteremia has been caused by an existing identifiable infection close to the endograft site (Murphy, et al, 2013).

Endograft Complications

- Patients with infected endografts are most commonly present with evidence ofsepsis, aortic fistula or aortic rupture (Murphy et al, 2013).

- Incidence rare 0.2 to 5% (Smeds, et al.)

- Common comorbidities:

- Hypertension

- Other Cardiac risk factors

- Diabetes Mellitus

Endograft Infection

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Operative Procedure: Post Op Day 0

o Deep vein harvest (Rt thigh)

o Removal of infected aortic stent graft (EVAR)

o Aortic interposition with aorto-iliac vein grafto EBL: 8L

→ received 6 units PRBCs, 2 u Plts, 2 u Plasma, 2 u Cell saver

o Total Clamp time: 46 mins suprarenalo Intra-op hypotension: norepinephrine and vasopressin IV initiated;

o Brief run of SVT followed by Junctional rhythm, then Atrial Fibrillation,o Amiodarone infusion initiated in OR, o PACU overnight.

Post-Op Day 1

- Admitted to Step-Down Unit

- BP improved, infusions (Norepi & Vasopressin) stopped

- Amiodarone @ 22mg/hr continued for Afib

- U/O 30cc/hr:- RL 500ml, then RL @ 150cc/hr

- Hgb 78, Plt 164, WBC 9.3, Cr 166 (baseline 90s), K 6.1,

- Sept 2018 Graft Culture & Blood Cx: - MSSA & Granulicatella adiacens- Abx was changed from Septra to Pen G 2 million units IV q4hr and Cefazolin 2g IV q12hr due to

resistance- Repeat Blood Cx, PICC d/c’d

Post-Op Day 2

- c/o SOB, diaphoretic, wheezing on expiration, crackles, green sputum, and 1-2 words sentences only

- Requires 6LFM for O2sat 94-95%, was previously on 5LNP

- Generalized edema, u/o 25-40cc/hr

- Cr 272

- CXR: bilateral pleural effusions and vascular distension - IVF stopped, Lasix 80mg IV x2 doses then to be reassessed

- No BS/flatus, nauseated (tx w/ Ondasentron)

Post-Op Day 3

- Inc O2 demand overnight, 6LFM to 10L OM → 15L NRB:

- ABG 7.32/44/133/23 IN AM 10 LFM 100%; O2sat decreased to 88%; improved with 15L NRB at 97%

- CXR showed pulmonary edema,

- UOP: (100-200cc/hr), Cr 330 (from 270) Nephrology consulted

- Lasix held d/t inc Cr

- Lethargy, Naloxone 0.4mg given w/ effect

- Abd distended, no BS/flatus, nauseated,- NG inserted - AXR: suspected ileus

- D51/2NS @ 75cc/hr

- PICC inserted

Post-Op Day 4/5/6- CVS: SR with occ’l PVCs & accelerated junctional, Amiodarone stopped,

generalized edema remains

- Resp: 96-98% on 3L/NP, CPAP @ HS, RR 12-16, wet productive cough producing thick green sputum

- GI/GU: - POD#4 +BS/flatus, NG clamped, s/a BM POD#5: CF startedDAT at POD#6- UOP: ~2-5L/24hrs (auto-diuresing), Cr 380, K 3.4 Ur 18- Lasix 40mg PO OD started

- ID: - Cultures sourced from AAA sac and adjacent soft tissue: MSSA, S. lentus, S. anginosus, Prevotella, veillonella bacteria

- Repeat blood cultures from POD #1 negative- Abx changed to Cloxacillin, Ceftriaxone and Metronidazole for 6 weeks

- Mobilizing w/ Physiotherapy and nursing, gutter walker & up in chair

- Transferred to ward

Post-Op Day 7

- Pt ℅ drowsiness, talking in sleep and vivid dreams

- Vascular Sx: MRI spine to evaluate source of infection

- Episode of Epistaxis at hs, previous hx at home

- 4-5BM Liquid BMs:- C Diff sample sent

- Cr 330 from 353

- K 2.9, Mag 0.34 Replaced

- Nutrition consulted: calorie counts

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Post-Op Day 8

- MRI Spine: - Acute episode of Epistaxis

- Coughing up blood, unable to lie flat

- Hgb 88, Plt 209, INR 2.3; - Vitamin K given, held Heparin SC & ASA- Stat CBC & LFTs ordered

- ENT Consult: Rt Nare packed to control bleed

- Confusion: Paranoia- Foley d/c’d, - MSU/UA sent

- Large BM with Frank Bleeding/+Clots: NPO- Pantoprazole Infusion started; - GI consulted: Scope ordered

Post Op Day 9-10

- GI: - EGD & colonoscopy- Fresh blood in oropharynx & clear UGI- Internal hemorrhoids, inconclusive to cause of GI bleed

- Pantoprazole infusion continued

- Hgb dropped from 85 to 69; - Transfused w/ 1 unit PRBC- Hgb 72 post transfusion

- MCV 95.1 & Plt 221 (normal)

- INR: 1.2 from 2.3

Post-Op Day 11

- MRI (Spine): completed without contrast- Fluid collection ~5-14cm- Radiology recommended aspirate of large lumbar collection and repeat

imaging in 2-3 weeks

- Ortho-Spine Consult:- CT scan to reassess stability of lumbar spine

Post-Op Day 12

- CT lumbar spine:

- Minor screws loosening but

hardware is intact and unchanged

Post-Op Day 13-18

- ℅ chills and fatigue- CPAP not been used due to nosebleeds, pt refused to wear

- Poor PO intake, Nauseated- Tx with IV Ondansetron- Nutrition: med pass initiated

- Mobility: limited by poor endurance, deconditioning

Post-Op Day 19-24

-POD#19: ℅ chest pain, chills, fatigue and SOB - Hgb 57 from 90: transfused 2 units PRBCs- EKG: nil acute but increase in HTNT 230, - Cardiology consulted: Type II MI:

- Recommendation: Keep Hgb over 80- Telemetry

- CTA: no evidence of bleed or fistula, incomplete SBO/ileus noted

- POD#20 ++ Loose stools, + melena C.Diff sent- GI re-consulted:

- Tagged RBC scan: no active bleeding- Suggested Hematology consult

- Capsule endoscopy: not applicable at the moment due to incomplete SBO

- POD#24 NGT re-inserted

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Post-Op Day 25

- Poor oral intake due to nausea, - Routine anti-emetics

- Due to inability to meet nutritional needs: - TPN started and continue to encourage PO intake

- ID:- Continue IV abx for minimum for 6 weeks - Reassess radiographic resolution of lumbar spine collection in 6 weeks

- Hematology:- No further investigation as labs Hgb 88; stabilized

Post-Op Day 30- 40

- Epistaxis & Hgb 66 - 2 units PRBCs

- GI scope:

- Duodenal angiodysplasia w/ active ooze bleeding at duodenum and distally

- Pantoloc 40 mg IV BID started

- CF diet in the next 24 hrs.

- Pt. had ongoing anxiety/emotional episodes, “I just don’t feel right”- Lorazepam PRN initiated

- TFT levels ordered

- ℅ unresolved migraine - Neuro consulted

Post-Op Day 40-45 - SVT HR 140-150s:

- Metoprolol and telemetry

- Cardiology re-consulted:

- Fluid restrict

- ℅ pain to hands and feet, x-ray done

- No obvious psoriatic arthritis

- Rheumatology consulted to investigate ?vasculitis

- Urine protein & micro, Cr ordered

- TSH > 100: Endocrinology consulted- Reviewed levothyroxine levels, ? poor absorption

- Levothyroxine 200mcg PO / OD w/ monitoring TFT levels

Post-Op Day 46-55

- Endocrinology:

- L-thyroxine dose changed to 50 mcg IV OD x 3 days,

- Lispro was restarted to control DM

- GI re-consulted d/t pt had melena/black stool

- Gastroscopy: globule of blood in esophagus and oropharynx washed off easily, no bleeding source identified

- Patency Capsule test started

- Hgb 65 (2 units PRBC transfused)

- Episode of V-tach

- increased Metoprolol dose to 37.5 mg PO TID

- Rheumatology: - suggested Nephrology consult regarding proteinuria, to assess - ? autoimmune vs HTN

Post-Op Day 56-60

- GI:

- Unable to confirm placement of capsule (?distal ileum/ R colon)

- Rheumatology signed off ;

- MPO (Myeloperoxidase) antibodies presence was infection induced and would resolve as the infections treated (f/u post discharge)

- Fatigue & cold intolerance have improved but lack of appetite remains; slowly progressing with endurance & mobility

- Endocrine: decrease dose L-thyroxine 250 mcg PO OD

Post-Op Day 61-65

- GI: Capsule didn’t get stuck due to obstruction but had a prolonged

transit (~72 hrs)

- Patency test failed: not safe for video capsule test

- CT abd: no evidence of small bowel or large bowel obstruction

- Endocrine:

- Trial to return to home dose of L-thyroxine 150 mcg PO OD

- Nephrology:

- Tubular range proteinuria is not attributable to vasculitis

- Only way to confirm is biopsy which is not recommended at this point

- To follow Cr

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Post-Op Day 66-79

- Cr 107

- CXR: Pulmonary edema, SOB, decrease O2 sats while in PT

- Lasix IV then step down to PO, CPAP @ hs

- GI:

- CT enterography: no bleed, mesenteric arteriovenous malformations, signed off

- Gold Sx consulted:

- Opinion for SBFT for poor PO intake

- Re-evaluate intake through calorie counts to wean off TPN

- Pt prefers not to have SBFT, optimize PO intake

- Endo: signed off:

- L-thyroxine 150mg PO OD (home dose)

POD 80- 83 (Discharge)

- Pt. discharged:w/ 2L FR

Refused Home Care

Nutrition community service offered to patient

Follow up 6 weeks- Follow up CTA in 1 year- GI: regular capsule endoscopy to follow up re: bleeding- Antibiotics discontinued prior to discharge

Barriers to Discharge

- Lengthy hospital admission with multiple complications

- Recurrent anemia and GI bleeding

- Severe hypothyroidism

- Type 2 MI

- Post op ileus/ Partial small bowel obstruction

- Graft Infection & Lumbar Spine Infection

- Long term IV Abx

- Poor Nutrition/TPN

Discharge Planning: Interprofessional Collaboration

- Infectious Disease - Nursing

- Cardiology - Physiotherapy

- Rheumatology - Occupational Therapy

- Hematology - Nutrition

- Vascular Team - PICC team

- Endocrine - Psych Liason

- Gastrointestinal - Spiritual Care

- Ortho Spine - Home Care

Medical Consults◎ ID

◎ Anesthesia

◎ Cardiology

◎ Endocrine

◎ Rheumatology

◎ Ortho Spine

◎ Neuro

◎ Gastrointestinal

◎ ENT

◎ Hematology

◎ Nephrology

Management of EVAR infections

- Assessment- Diagnosis- Planning- Implementation- Evaluation

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Management of EVAR – Applications for nursing

- Assessment - signs of sepsis early(confusion, elevated WBC, positive blood cultures, identifying fevers,), chest or abdominal pain, rigors, bleeding, frank rupture, or anorexia

- Diagnosis – CTA, labs, blood cultures, possible bronchoscopy, gastroscopy, X-ray,

- Planning – Interprofessional collaborative care

- Implementation – of strategies to reach discharge goals

- Evaluation – the plan of care, daily nursing assessments, be vigilant for complications should they arise

Conclusion

- EVAR infection is rare- Lack of research evidence to fully guide management

ReferencesDaye, D., & Walker, T. (2017). Complications of endovascular aneurysm repair of the thoracic and abdominal aorta:

Evaluation and management. Cardiovascular Diagnosis and Therapy, 8 (1). Retrieved from http://cdt.amegroups.com/article/view/16911/19122

Karthikesalingam, A., & Holt, P.(2016). Multicentre Post-EVAR Surveillance Evaluation Study (EVAR-Screen). European Journal of Vascular & Endovascular Surgery, 52 (3). P. 55-56. DOI: https://doi.org/10.1016/j.ejvs.2016.05.025

Murphy, E.H., Szeto, W.Y., Herdrich, B.J., Jackson, B.M, Wang, G.J., Bavaria, J.E., Fairman, R.M.,...Woo, E.Y. (2013). The management of endograft infections following endovascular thoracic and abdominal aneurysm repair. Journal of Vascular Surgery, 58 (5), p.1179-1185

Lyons, O.T.A., Patel, A.S., Saha, P., Clough, R.E., Price, N., & Taylor, P.R. (2013). A 14-year experience with aortic endograftinfection: Management and results. European Journal of Vascular and Endovascular Surgery, 46 (3), p.306-312. doi:10.1016/j.ejvs.2013.04.021

Smeds, M.R., Duncan, A.A., Harlander-Locke, M.P., Lawrence, P.F., Lyden, S., Fatima, J.,...Eskandari. (2016). Treatment and outcomes of aortic endograft infection. Journal of Vascular Surgery, 63 (2), p.332-340. doi:10.1016/j.jvs.2015.08.113

Strøm, M., Lönn, L., Bech, B., Schroeder, T., & Konge, L. (2017). Assessment of Competence in EVAR Stent Graft Sizing and Selection. European Journal of Vascular and Endovascular Surgery,53(6), 844-852. doi:10.1016/j.ejvs.2017.03.007

Grima, M. J., Karthikesalingam, A., & Holt, P. J. (2018). Multicentre Post-EVAR Surveillance Evaluation Study (EVAR SCREEN). European Journal of Vascular Surgery and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2018.10.032

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JOURNEY BACK TO LIFE:COMPLEX TEVAR

ALEXANDRA KEKS RN, BSN VASCULAR SURGERY, RCH-3NORTH

OUTLINE

Initial clinical presentation of Mr. B

Overview of normal Aorta vs. Type B dissections

Interventions for Mr. B

Complications with post-op recovery

Outcome- where is he now

BACKGROUND

December 2017 felt sharp pain after fall

January 2018 woke up with weakness, abdo and back pain

EHS to Delta Emergency

PMHx: Smoker, Anxiety and

Depression otherwise medically well

Age: 60

ER PRESENTATION:

Mr. B presents to Delta, his community hospital.Physical ExamWeakness in legs, accompanied by severe abdominal and back painVitals: BP 176/100 P: 80 RR: 30Diagnostics: CT scan to rule out spinal cord injuryCT showed significant abnormality of the aorta

TRANSFER TO ROYAL COLUMBIAN HOSPITAL

CT FINDINGS

Ouzounian (2013)

TYPE B DISSECTION;

It was found that the type B dissection started from subclavian artery extending to the iliac arteries.

CT FINDINGS

Starting at subclavian artery with several re-entry tears

Poorly perfused superficial mesenteric artery and celiac artery

No blood flow down right common iliac system

Recurrence of flow to the common femoral and collaterals

Left side dissection flap ending at the distal external iliac

JANUARY 2ND 2018; CTA AXIAL IMAGE

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INITIAL VASCULAR ASSESSMENT

Right leg numbness greater than left

Bilateral leg weakness

Palpable DP pulse to left and absent pulses to right

Consult by vascular surgeon and brought to OR urgently for TEVAR

① Aortic root

② Ascending Aorta

③ Aortic Arch

④ Descending

Thoracic Aorta

THE NORMAL THORACIC AORTA:

Diaphragm

American Heart Association(2005)

TYPE B DISSECTION:

A tear in the inner wall of descending part of the aorta, may extend into abdomen • Blood escapes from the lumen of the aorta into the lining once it enters the lining it separates the layers of the aortic wall

Signs and symptoms: (similar to heart attack)• Sudden onset severe pain• change in pulse• sob• sweating• loss of consciousness

Christopher G. Harris,* Beth Croce, and David H. Tian

RISK FACTORS

Men 60s- 70s years of age

Increased blood pressure- results in greater stress against the aortic wall

Atherosclerosis, high cholesterol, smoking, valve defects, previous aortic aneurysm, trauma

Genetic: Marfan’s syndrome, Ehlers-Danlossyndrome

https://columbiasurgery.org/conditions-and-treatments/aortic-dissection

http://www.aorta.ca/diseases/type-b-dissection/

• Rupture of aorta leading to death

• Lack of adequate blood flow to the spinal cord, bowel, kidneys and legs

• Once the aorta has torn, it is at risk for forming an aneurysm with time

COMPLICATIONS OF TYPE B DISSECTION

MEDICAL MANAGEMENT VS SURGICAL APPROACH:

•Medical management usually preferred. – medications given to decrease BP and HR. Does not necessarily need surgical intervention.

•Surgical Management chosen when complications arise and involves insertion of a stent or graft

Cronenwett & Johnston (2014)

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Mr. B was transferred urgently to RCH and was taken into the operating room for TEVAR

OR STAT…

INTERVENTIONS

① TEVAR January 2, 2018

② Transfer to ICU

③ Fasciotomy Jan 3rd surgical repair of closure and VAC application

④ Transfer to vascular inpatient unit

⑤ Flap closure to right thigh/hip Feb 9th

⑥ Aortic valve repair and tube graft Feb 11th and transfer to cardiac unit then back to vascular

⑦ Transfer to Delta hospital Feb. 24th for further medical stabilization and physio treatment

⑧ Transfer to GF strong in patient rehabilitation

MR. B’S COMPLICATIONS:

• Paralysis • GU: AKI , rhabdo , hemodialysis, urinary

retention long term indwelling catheter • GI: stenosis of celiac artery, bowel hypoperfusion• Right thigh compartment syndrome• Long stay in hospital• Pressure ulcer on sacrum • Type A dissection

POST-OP NURSING CARE:

•Complex in nature due to the case

Close monitoring of peripheral neurovascular status:

• Monitoring CWMS in lower limbs.

- Any change in sensory or motor function should bereported immediately

• Monitoring vital signs focusing on blood pressure

Wound care of surgical incisions

Emotional, holistic, realistic care

OUTCOME

September 2019

•“I was never actually scared….even when the guy said it was either surgery or I would be dead in 12 hours, I just said do what ya gotta do doc”

•Lives with his parents in Ladner, BC and told his family I want a year to do “nothing”

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The Patient Experience Around Connecting the Dots: Mycobacterial

Graft Infection and BCG Bladder Treatment

Hilary Doucet RN, BN

Vascular Surgery

NSHA Central Zone

Meet D.L.

77 year old male

Lives with wife in rural Nova Scotia

Has 4 children

Retired mechanic and used car salesman

Very Social and active

History

Medical

Peripheral Vascular Disease

Hypertension

Bladder Cancer

Parastomal hernia

Surgical

Appendectomy

TURBT

Cystectomy

Health Care VisitsInitial health concern

2012

Diagnosis: Progressive urothelial cell carcinoma of the bladder

Treatment:

Multiple cystoscopies and TURBTs

Chemotherapy (BCG bladder treatment)

Cystectomy and creation of ileoconduit

BCG Bladder Treatment

Intravesical therapy

Bacillus Calmette-Guiren

Bacteria inserted directly into the bladder to kill cancer cells

Mycobacterium bovis is a strain of bacteria that causes tuberculosis

Side effects

Side Effects

Initial symptoms:

Frequent urination

Urgent urination

Burning during urination

Flu-like symptoms

Loss of appetite

Delayed symptoms:

Fatigue

Diarrhea

Rash

Nausea and vomiting

Loss of appetite

Myelosuppression

Lung problems

Inflammation of any organ

Canadian Cancer Society (cancer.ca)

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Health Care VisitsVascular Surgery

2013

Chief complaint: lower abdominal and back pain x 1 month

Diagnosis: Contained rupture and ulceration of known AAA

AAA measuring 3cm in March 2013

AAA measuring 4.9cm in June 2013

Mycotic aneurysm

Treatment: EVAR

Discharged home

Mycotic Aneurysm

Infection within a dilated arterial wall

Very rare (1% of surgically corrected AAA)

Difficult to diagnose

Mortality rate 15-50%

More prevalent in malesRisk Factors:• Immunosuppression• Alcohol abuse• Radiotherapy • Chronic renal failure

Health Care Visits

2013-2014

Multiple ER visits

Chief complaint: abdominal pain

Numerous follow-up appointments

September 2013

Changes noted around the aorta

Ciprofloxacin 500mg PO BID indefinite

November 2013

Right groin seroma

Continue antibiotics

Health Care Visits Numerous follow-up appointments

May 2013

Inflammation to distal end of aorta

Surgery (Axillobifemoral bypass graft) vs. conservative management

Admission

November 2015

Diagnosis: Contained rupture/penetrating ulceration of the distal thoracic aorta

Mycotic aneurysm

Treatment: TVAR

Lab values normal

Antibiotics discontinued

Discharged home

Health Care Visits

Admission

August 2017

Diagnosis: Abscess in the thoracic aortic aneurysm sac

Treatment: Needle aspiration in IR

Cultures negative

ID consulted

All antibiotics discontinued

Multiple ER visits

Several needle aspirations

Cultures negative

Health Care Visits

Admission

November 2018

Diagnosis: Infected aortic graft

Treatment: Perc drain insertion

Samples sent for C+S (negative) and AFB (positive)

New diagnosis: Mycobacterial infection likely related to BCG bladder treatment

ID consulted

Antibiotic treatment: Rifampin, Isoniazid, Ethambutol, Vitamin B6

Airborne precautions

Perc drain removed

Discharged home

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Implications for Nursing Care

Controversial

Precautions vs. No Precautions

Limited resources/awareness

Effects on the Patient

Psychological

Upsetting

Confusion

Lonely

Physical

Multiple hospital visits

Difficult diagnosis

Routine disruptions

Auditory difficulties

Visual changes

Health Care Visits

Followed in the community by ID

Admission

January 2019

Diagnosis: New collection to graft

Treatment: Needle aspiration in IR

Discharged home

Follow-up ID

July 2019

Unable to cure infection

Possible palliative care consult

References

Deipolyi, A.R., Rho, J., Khademhosseini, A., Oklu, R. (2016). Diagnosis and management of mycotic aneurysms. Clinical Imaging, 40(2), 256-262.

Psoinos, C.M., Simons, J.P., Baril, D.T., Robinson, W.P., Schanzer, A. (2012). A mycobacterium bovis mycotic abdominal aortic aneurysm resulting from bladder cancer treatment, resection, and reconstruction with a cryopreserved aortic graft. Vascular and Endovascular Surgery, 47(1), 61-64.

Roeke, T., Hovsibian, S., Schlejen, P.M., Dinant, S., Koster, T., Waasdorp, E.J. (2018). A mycotic aneurysm of the abdominal aorta caused by Mycobacterium Boris after intravesical instillation with bacillus Calmette-Guerin. Journal of Vascular Surgery Cases and Innovative Techniques, 4(2), 122-125.

Yong, D., Roake, J.A., Buckenham, T., Lewis, D.R. (2008). Endovascular repair of mycotic aortic aneurysms. The New Zealand Medical Journal, 121(1269), 64-67.

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