Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
82 Cards in this Set
- Front
- Back
|
What is the new method of quality assurance and how is it different from classical QA? |
QI involves both prospective and retrospective reviews. It is aimed at improvement—measuring where you are and figuring out ways to make things better. It specifically attempts to avoid attributing blame and to create systems that prevent errors from happening. It is a continuous process (also known as continuous quality improvement or CQI) that must occur consistently in an ongoing fashion, unlike the QA entity, which is static. |
|
|
Six IOM quality aims |
Care that is: 1. Safe 2. Timely 3. Effective 4. Efficient 5. Equitable 6. Patient-centered. |
|
|
Six core competencies of MOC |
1. Patient Care—Provide care that is compassionate, appropriate, and effective treatment for health problems and to promote health. 2. Medical Knowledge—Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and their application in patient care. 3. Interpersonal and Communication Skills—Demonstrate skills that result in effective information exchange and teaming with patients, their families, and professional associates (e.g., fostering a therapeutic relationship that is ethically sound and uses effective listening skills with nonverbal and verbal communication; working as both a team member and at times as a leader). 4. Professionalism—Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diverse patient populations. 5. Systems-based Practice—Demonstrate awareness of and responsibility to larger context and systems of healthcare. Be able to call on system resources to provide optimal care (e.g., coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions, or sites). 6. Practice-based Learning and Improvement—Able to investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve the practice of medicine. |
|
|
The two core management principles of Lean are: |
relentless elimination of waste and respect for people with long-term relationships among employer, employee, suppliers, and customers, based on continuous improvement and mutual trust. |
|
|
Lean Tool set: |
Value Stream Mapping Five S Pull Systems “Just-in-Time” Error-proofing |
|
|
Value Stream Mapping |
a tool to help understand and improve the material and information flow within a process. The end product is a visual flow map, in a simple graphical format, of the whole process from end to end in a method that is easy to understand by those working through the process. The graphic format encourages |
|
|
The Five S tool |
focused on standardization of work areas. Goals are to eliminate clutter, establish “a place for everything and everything in its place,” standardize the manner in which work flows across the station, and maintain the new simplified state. The Five S process is necessary, but not sufficient, in Lean improvement processes. Five S: (translated from the Japanese seiri, seiton, seiso, seiketsu, and shitsuke) Sorting Straightening Systematic cleaning Standardizing Sustaining |
|
|
Pull systems, just-in-time |
or kanban, are system fundamentals that differentiate Lean and TPS from more common assembly line practices of overproducing at individual work steps, thus creating large piles of inventory that must be stored or inventoried until actually needed by the next process step. Inventory or work accumulating in queue is a fundamental source of waste. In theory, pull systems work to emulate one-piece flow where the next step of work on an item occurs immediately at the completion of the prior step, the prior step is not creating any more than the next step can handle, and the next step is not idly waiting on the prior step for work. In practice, this is managed by producing a small buffer of inventory and implementing alert systems (kanbans) that signal readiness for additional parts or work. Pull-systems and kanbans are practical solutions to the unreality of true, consistent one-piece flow. The small inventories and need for signaling is viewed as “necessary waste”—useful, but to be minimized. |
|
|
Error-proofing |
a concept of defining and standardizing process steps and quickly addressing new sources of error with further refinement of the steps. Recognition of error or defect obligates a team member to “stop the line,” or draw immediate attention to the defect so that supervisors and problem-solving teams can address the defect and the variation in process that caused it. It is systems-focused inquiry, rather than individually focused, thus maintaining the goodwill of the team members. Smoothness of workflow from end to end is the ultimate goal of Lean systems. Poor flow results from two primary issues: 1) unreasonable work due to poor organization and 2) pushing beyond natural limits. Poor organization induces moving things around, awkward transitions, potentially dangerous tasks, and uneven tempo of work. Pushing beyond natural limits leads to shortcuts, idiosyncratic decision making, and multiple variations in process. It is important to note once again that this view focuses on system impositions on workers rather than flawed employees. |
|
|
Design-Measure-Analyze-Improve-Control |
The Six Sigma version of this process is DMAIC: Design-Measure-Analyze-Improve-Control. This refers loosely to striving for near perfection in the performance of a process or production of a product. The name derives from the Greek letter sigma, often used to refer to the standard deviation of a normal distribution. By definition, 95 percent of a normally distributed population falls within two standard deviations of the average (or “2 sigma”). This leaves 5 percent of observations as “abnormal” or “unacceptable.” Six Sigma targets a defect rate of 3.4 per million opportunities—six standard deviations from the population average. |
|
|
QI tools |
Brainstorming Cause-and-effect diagram Flowcharts Multivoting Nominal Group Technique (NGT) Prioritization matrix Walk-through |
|
|
Multivoting |
Multivoting is a simple, structured approach used by teams to select the most significant or highest priority item from a list. This process relies on popular opinion and is a method of prioritizing projects or elements of projects. It usually follows a brainstorming session that has generated many ideas. |
|
|
Nominal Group Technique (NGT) |
This is a more formal and structured approach to generating a list of ideas or merging them into a more sustainable number. The term “nominal” is used to denote the minimal conversations or interactions among the team. This approach can be quite effective for discussing controversial concepts. It also allows for defusing a domineering staff member or influential employee who tends to control the discussion and be the prevailing voice. NGT promotes team ownership of decision-making. |
|
|
Key NPSGs involving radiology practices (hospital and ambulatory) include |
Use at least two patient identifiers when providing care, treatment, and services Report critical results of tests and diagnostic procedures on a timely basis Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings Maintain and communicate accurate patient medication information Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines Implement evidence-based practices to prevent healthcare–associated infections due to multidrug-resistant organisms in acute care hospitals Implement evidence-based practices to prevent central line–associated bloodstream infections Conduct a pre-procedure verification process Mark the procedure site Perform a time-out before the procedure
|
|
|
IOM defined types of medical errors |
1. Diagnostic a. Error or delay in diagnosis b. Failure to employ indicated tests c. Use of outmoded tests or therapy d. Failure to act on results of monitoring or testing 2. Treatment a. Error in the performance of an operation, procedure, or test b. Error in administering the treatment c. Error in the dose or method of using a drug d. Avoidable delay in treatment or in responding to an abnormal test e. Inappropriate (not indicated) care 3. Preventive a. Failure to provide prophylactic treatment b. Inadequate monitoring or follow-up of treatment 4. Other a. Failure of communication b. Equipment failure c. Other system failure |
|
|
IOM Ten Rules for Redesign |
1. Care is based on continuous healing relationships. Patients should receive care whenever they need it, and in many forms, not just face-to-face visits. This implies that the healthcare system must be responsive at all times, and access to care should be provided over the Internet, by telephone, and by other means in addition to in-person visits. 2. Care is customized according to patient needs and values. The system should be designed to meet the most common types of needs, but it also should have the capability to respond to individual patient choices and preferences. 3. The patient is the source of control. Patients should be given the necessary information and opportunity to exercise the degree of control they choose over healthcare decisions that affect them. The system should be able to accommodate differences in patient preferences and encourage shared decision making. 4. Knowledge is shared and information flows freely. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information. 5. Decision making is evidence based. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place. 6. Safety is a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors. 7. Transparency is necessary. The system should make available to patients and their families information that enables them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction. 8. Needs are anticipated. The system should anticipate patient needs, rather than simply react to events. 9. Waste is continuously decreased. The system should not waste resources or patient time. 10. Cooperation among clinicians is a priority. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care. |
|
|
Human Factors Engineering Issues
|
Usability Testing Workarounds forcing Functions Standardization Resiliency Efforts
|
|
|
Patient Safety Communication recommendations |
Communication plays a role in achieving patient safety, removing barriers that affect patient-practitioner interactions, and disclosure of adverse events, including: (1) telling the patient and family what happened in terms they can understand; (2) taking responsibility; (3) apologizing; and (4) explaining what will be done to prevent similar errors, improved transitions of care—specific strategies. |
|
|
culture of safety tenets |
Beliefs, attitudes, and values about work, risk, and safety The value of learning Distinction between errors resulting from deliberate unsafe acts and errors that are a result of system failures. |
|
|
culture of safety key features |
acknowledgment of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations; a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment; encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems; and organizational commitment of resources to address safety concerns. |
|
|
active error definition |
Active errors occur at the point of contact between a human and some aspect of a larger system (e.g., a human-machine interface). They are generally readily apparent (e.g., pushing an incorrect button, ignoring a warning light) and almost always involve someone at the front line. Active failures are sometimes referred to as errors at the |
|
|
latent error definition |
less apparent failures of organization or design that contribute to the occurrence of errors or allow them to cause harm to patients. To complete the metaphor, latent errors are those at the other end of the scalpel—the blunt end—referring to the many layers of the healthcare system that affect the person “holding” the scalpel. |
|
|
Adverse Drug Event (ADE) |
An adverse event (i.e., injury resulting from medical care) involving medication use. Examples: anaphylaxis to penicillin major hemorrhage from heparin aminoglycoside-induced renal failure agranulocytosis from chloramphenicol |
|
|
ameliorable ADE |
one in which the patient experienced harm from a medication that, while not completely preventable, could have been mitigated |
|
|
Adverse Drug Reaction |
Adverse effect produced by the use of a medication in the recommended manner, i.e., a drug side effect. These effects range from nuisance effects (e.g., dry mouth with anticholinergic medications) to severe reactions, such as anaphylaxis to penicillin. Adverse drug reactions represent a subset of the broad category of adverse drug events—specifically, they are non-preventable ADEs. |
|
|
Adverse Event |
Any injury caused by medical care. |
|
|
Authority Gradient |
Authority gradient refers to the balance of decision-making power or the steepness of command hierarchy in a given situation. Members of a crew or organization with a domineering, overbearing, or dictatorial team leader experience a steep authority gradient. Expressing concerns, questioning, or even simply clarifying instructions would require considerable determination on the part of team members who perceive their input as devalued or frankly unwelcome. |
|
|
Blunt End |
The blunt end refers to the many layers of the healthcare system not in direct contact with patients, but which influence the personnel and equipment at the sharp end who do contact patients. The blunt end thus consists of those who set policy, manage healthcare institutions, and design medical devices, and other people and forces, which, though removed in time and space from direct patient care, nonetheless affect how care is delivered. |
|
|
Close Call (Near Miss |
This is an event or situation that did not produce patient injury, but only because of chance. |
|
|
Mistakes |
In some contexts, errors are dichotomized as slips or mistakes, based on the cognitive psychology of task-oriented behavior. Mistakes reflect failures during attentional behaviors—behaviors that requires conscious thought, analysis, and planning, as in active problem solving. Rather than lapses in concentration (as with slips), mistakes typically involve insufficient knowledge, failure to correctly interpret available information, or application of the wrong cognitive heuristic or rule. |
|
|
Potential ADE |
A potential adverse drug event is a medication error or other drug-related mishap that reached the patient but happened not to produce harm |
|
|
Sentinel event |
According to the Joint Commission, “a sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.” Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response. |
|
|
tools for evaluating risk and adverse events |
Failure Mode and Effects Analysis (FMEA) Root Cause Analysis (RCA) Medication Reconciliation
|
|
|
Periprocedural care |
Periprocedural care pt id assessment informed consent time out hand washing |
|
|
Levels of sedation |
1. Minimal sedation or anxiolysis: The administration of medications for the reduction of anxiety and a drug-induced state during which the patient responds to verbal commands. In this state, cognitive function and coordination may be impaired, but ventilatory and cardiovascular functions are unaffected. 2. Moderate sedation/analgesia: A minimally depressed level of consciousness induced by the administration of pharmacologic agents in which the patient retains a continuous and independent ability to maintain protective reflexes and a patent airway and to be aroused by physical or verbal stimulation. 3. Deep sedation/analgesia: A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. 4. General anesthesia: A controlled state of unconsciousness in which there is a complete loss of protective reflexes, including the ability to maintain a patent airway independently and to respond appropriately to painful stimulation. |
|
|
American Society of Anesthesiologists (ASA) Physical Status Classification |
Class I - A normal healthy patient; Class II - A patient with mild systemic disease; Class III - A patient with severe systemic disease; Class IV - A patient with severe systemic disease that is a constant threat to life; Class V - A moribund patient who is not expected to survive without the operation; Class VI - A declared brain-dead patient whose organs are being removed for donor purposes. |
|
|
MR site into four zones |
Zone I: Access is unrestricted, but this is the area through which patients and others access the controlled MR environment. Zone II: This is the interface between the uncontrolled, publicly accessible Zone I and the strictly controlled Zones III and IV. Zone II may be used to greet patients, obtain patient histories, and screen patients for MR safety issues. Patients in Zone II should be under the supervision of MR personnel. Zone III: This is the area where there is potential danger of serious injury or death from interaction between unscreened people or ferromagnetic objects and the magnetic field of the scanner. The scanner control room is typically in Zone III. Access to Zone III must be strictly restricted and under the supervision of MR personnel with physical restriction such as locks or passkey systems. It is important to remember that the magnetic field is three-dimensional. Thus, the restricted area may extend not only in all directions on the same floor of the facility but also potentially through the floor and/or ceiling to adjacent floors. Zone IV: This is the MR scanner magnet room and therefore is the highest risk area. This zone should be clearly demarcated and marked as potentially hazardous due to the strong magnetic field. Access to Zone IV should be under direct observation of MR personnel. When a medical emergency occurs, the patient should be immediately removed to a magnetically safe location while resuscitation or stabilization is begun. |
|
|
With use of low osmolality contrast media, large studies have shown an overall incidence of reactions of: |
With use of low osmolality contrast media, large studies have shown an overall incidence of reactions of 0.2-0.7 percent. |
|
|
notes on screening for iodinated contrast reaction |
Safe administration of contrast begins with a focused patient history to identify factors that may increase the likelihood of a reaction or may contraindicate the administration of contrast. The greatest risk factor for an allergic-like reaction to contrast is a history of a prior reaction to contrast, which is associated with a five times increased risk of subsequent reaction. Any other allergic history, but particularly a history of major anaphylactic reaction, may increase the patient’s risk, but some specific allergies such as to shellfish are no longer considered to be highly significant. However, atopy results in a 2-3 times increased risk of contrast reaction. Asthma may also increase the risk of contrast reaction. Significant cardiac disease also imparts an increased risk. There is controversy as to whether patient anxiety increases the risk of a contrast reaction. |
|
|
The two most frequently used elective premedication regimens as listed in the ACR Contrast Manual are: |
i. Prednisone: 50 mg by mouth at 13 hours, 7 hours, and 1 hour before contrast media injection, plus Diphenhydramine (Benadryl®): 50 mg intravenously, intramuscularly, or by mouth 1 hour before contrast medium; or ii. Methylprednisolone (Medrol®): 32 mg by mouth 12 hours and 2 hours before contrast media injection. An anti-histamine (as in option 1) can also be added to this regimen injection. If the patient is unable to take oral medication, 200 mg of hydrocortisone intravenously may be substituted for oral prednisone in the Greenberger protocol. |
|
|
When contrast administration is required in a shorter time-frame, there is less evidence of efficacy of premedication and less agreement on the optimal regimen since IV steroids have not been shown to be effective when administered fewer than 4-6 hours prior to contrast injection. The ACR Contrast Manual lists the following options, in decreasing order of desirability: |
i. Methylprednisolone sodium succinate (Solu-Medrol®) 40 mg or hydrocortisone sodium succinate (Solu-Cortef®) 200 mg intravenously every 4 hours (q4h) until contrast study required plus diphenhydramine 50 mg IV 1 hour prior to contrast injection; or ii. Dexamethasone sodium sulfate (Decadron®) 7.5 mg or betamethasone 6.0 mg intravenously q4h until contrast study must be done in patent with known allergy to methylprednisolone, aspirin, or non-steroidal anti-inflammatory drugs, especially if asthmatic. Also diphenhydramine 50 mg IV 1 hour prior to contrast injection; or iii. Omit steroids entirely and give diphenhydramine 50 mg IV. Corticosteroids should be used with caution in some groups of patients, including those with diabetes, uncontrolled hypertension, tuberculosis, systemic fungal infections, peptic ulcer disease, and diverticulitis. |
|
|
treatment for urticaria |
Urticaria 1. Discontinue injection if not completed. 2. No treatment needed in most cases. 3. Give H1-receptor blocker: diphenhydramine (Benadryl®) PO/IM/IV 25 to 50 mg. If severe or widely disseminated: give alpha agonist (arteriolar and venous constriction): epinephrine SC (1:1,000) 0.1 to 0.3 ml (=0.1 to 0.3 mg) (if no cardiac contraindications). |
|
|
treatment for facial or laryngeal edema |
Facial or Laryngeal Edema 1. Give O2 6 to 10 liters/min (via mask). 2. Give alpha agonist (arteriolar and venous constriction): epinephrine SC or IM (1:1,000) 0.1 to 0.3 ml (=0.1 to 0.3 mg) or, especially if hypotension evident, epinephrine (1:10,000) slowly IV 1 to 3 ml (=0.1 to 0.3 mg). Repeat as needed up to a maximum of 1 mg. If not responsive to therapy or if there is obvious acute laryngeal edema, seek appropriate assistance (e.g., cardiopulmonary arrest response team). |
|
|
treatment for bronchospasm |
Bronchospasm 1. Give O2 6 to 10 liters/min (via mask). Monitor: electrocardiogram, O2 saturation (pulseoximeter), and blood pressure. 2. Give beta-agonist inhalers (bronchiolar dilators, such as metaproterenol [Alupent®], terbutaline [Brethaire®], or albuterol [Proventil® or Ventolin®]) 2 to 3 puffs; repeat as necessary. If unresponsive to inhalers, use SC, IM, or IV epinephrine. 3. Give epinephrine SC or IM (1:1,000) 0.1 to 0.3 ml (=0.1 to 0.3 mg) or, especially if hypotension evident, epinephrine (1:10,000) slowly IV 1 to 3 ml (=0.1 to 0.3 mg). Repeat as needed up to a maximum of 1 mg. Call for assistance (e.g., cardiopulmonary arrest response team) for severe bronchospasm or if O2 saturation <88 percent persists. |
|
|
treatment for hypotension with tachycardia |
Hypotension with Tachycardia 1. Legs elevated 60 degrees or more (preferred) or Trendelenburg position. 2. Monitor: electrocardiogram, pulseoximeter, blood pressure. 3. Give O2 6 to 10 liters/min (via mask). 4. Rapid intravenous administration of large volumes of Ringer’s lactate or normal saline. If poorly responsive: epinephrine (1:10,000) slowly IV 1 ml (=0.1 mg) Repeat as needed up to a maximum of 1 mg. If still poorly responsive seek appropriate assistance (e.g., cardiopulmonary arrest response team). |
|
|
treatment for hypotension with bradycardia (vagal reaction) |
Hypotension with Bradycardia (Vagal Reaction) 1. Secure airway: give O2 6 to 10 liters/min (via mask). 2. Monitor vital signs. 3. Legs elevated 60 degrees or more (preferred) or Trendelenburg position. 4. Secure IV access: rapid administration of Ringer’s lactate or normal saline. |
|
|
treatment for hypertension, severe |
Hypertension, Severe 1. Give O2 6 to 10 liters/min (via mask). 2. Monitor electrocardiogram, pulseoximeter, blood pressure. 3. Give nitroglycerine 0.4 mg tablet, sublingual (may repeat x 3); or, topical 2 percent ointment, apply 1-inch strip. 4. If no response, consider labetalol 20 mg IV, then 20 to 80 mg IV every 10 minutes up to 300 mg. 5. Transfer to intensive care unit or emergency department. 6. For pheochromocytoma: phentolamine 5 mg IV (may use labetalol if phentolamine is not available). |
|
|
treatment for seizures or convulsions |
Seizures or Convulsions 1. Give O2 6 to 10 liters/min (via mask). 2. Consider diazepam (Valium®) 5 mg IV (or more, as appropriate) or midazolam (Versed®) 0.5 to 1 mg IV. 3. If longer effect needed, obtain consultation; consider phenytoin (Dilantin®) infusion – 15 to 18 mg/kg at 50 mg/min. 4. Careful monitoring of vital signs required, particularly of pO2 because of risk to respiratory depression with benzodiazepine administration. 5. Consider using cardiopulmonary arrest response team for intubation if needed. |
|
|
treatment for pulmonary edema |
Pulmonary Edema 1. Give O2 6 to 10 liters/min (via mask). 2. Elevate torso. 3. Give diuretics: furosemide (Lasix®) 20 to 40 mg IV, slow push. 4. Consider giving morphine (1 to 3 mg IV). 5. Transfer to intensive care unit or emergency department. Abbreviations: IM = intramuscular IO = intraosseous IV = intravenous PO = orally MR contrast agents NSF Extravasation risk factors, prevention, treatment |
|
|
contrast induced nephropathy definition |
A common |
|
|
The frequency of CIN |
The frequency of CIN is also difficult to determine, partly related to the lack of agreement on a single clinical definition. However, most studies have shown a risk of CIN of less than 10 percent, even in patients with moderate chronic kidney disease. In addition, recent studies have suggested that many cases of deterioration of renal function historically classified as CIN may be due to other coexistent and confounding factors. Newhouse et. al studied more than 30,000 patients in a single institution who did not receive iodinated contrast and found an increase in serum creatinine of at least 25 percent in more than half of the patients, and of at least 0.4 gm/dL in more than 40 percent. Had those patients received contrast, the changes might have been attributed to the contrast. Very few studies of CIN included a control group of patients who did not receive contrast. The authors of Version 8 of the ACR Manual on Contrast Media found only eight such studies, and only one of those (Bruce et. al) showed a greater risk of post-contrast serum creatinine elevation compared to the control group—and in that study, only in patients with a baseline creatinine value of 1.8 mg/dL or more. |
|
|
Risk factors for CIN are also controversial |
The ACR Manual on Contrast Media suggests a serum creatinine of 2.0 gm/dL in patients with chronic, stable renal insufficiency. Acute kidney injury is also considered a risk factor, and in that situation, the serum creatinine is not an accurate measure of actual renal function. Other proposed but less certain risk factors include diabetes mellitus, dehydration, cardiovascular disease, diuretic use, advanced age, multiple myeloma, hypertension, hyperuricemia, and multiple administrations of iodinated contrast media within 24 hours. Patients with end-stage oliguric renal stage on dialysis may be at risk of conversion to anuria. However, patients who have progressed to end-stage anuric renal disease are not at risk of CIN, although the osmotic load can present its own problems related to increased intravascular volume. |
|
|
The ACR Manual on Contrast Media suggests |
1) age >60; 2) history of renal disease (including dialysis, kidney transplant, single kidney, renal cancer, or renal surgery); 3) hypertension requiring medical therapy; 4) diabetes mellitus; and 5) metformin or metformin-containing drugs. (Note that metformin is not a risk factor for development of CIN, but patients who develop renal failure while taking metformin are at risk of developing lactic acidosis.) If the patient’s condition is stable, a creatinine value within 30 days of contrast administration is generally considered sufficient. |
|
|
In patients considered at increased risk of CIN, several strategies should be considered. |
Since most iodinated contrast is currently administered for CT scans, alternatives include performing only non-contrast scans or using other modalities such as ultrasound or MRI (usually without contrast due to risk of NSF). When contrast is deemed necessary and appropriate, use of the lowest dose possible may be helpful, although there is no clear proof of dose-related risk with IV administration of iodinated contrast. In patients with renal insufficiency, there is evidence that low osmolality contrast media (LOCM) are less nephrotoxic than high osmolality contrast media (HOCM), but HOCM are seldom used in current clinical practice in the United States. Various pretreatment strategies have been investigated for patients felt to be at risk of CIN. Of these, the most proven is intravenous hydration, preferably with isotonic fluids such as 0.9% saline or Lactated Ringer’s. A suggested protocol per the ACR Contrast Manual is infusion at 100 ml/hr for 6-12 hours before contrast administration and 4-12 hours after contrast administration. However, as with other studies related to CIN, most of the data relate to cardiac angiography. Data are mixed regarding the use of IV sodium bicarbonate and N-acetylcysteine, but the ACR Contrast Manual does not believe that these strategies are superior to IV hydration. Other strategies that have been investigated but have even less proven efficacy include mannitol (an osmotic diuretic), furosemide (a loop diuretic), theophylline, endothelin-1, and fenoldopam. In regard to these latter agents, the ACR Contrast Manual states, “Use of these agents to reduce the risk of CIN is not recommended.” |
|
|
The ACR Contrast Manual (version 7, 2010) states, “The frequency of all acute adverse events after an injection of 0.1 or 0.2 mmol/kg of gadolinium chelate |
The ACR Contrast Manual (version 7, 2010) states, “The frequency of all acute adverse events after an injection of 0.1 or 0.2 mmol/kg of gadolinium chelate ranges from 0.07 percent to 2.4 percent. The vast majority of these reactions are mild, including coldness at the injection site, nausea with or without vomiting, headache, warmth or pain at the injection site, paresthesias, dizziness, and itching.Reactions resembling an “allergic” response are very unusual and vary in frequency from 0.004 percent to 0.7 percent. A rash, hives, or urticaria are the most frequent of this group, and very rarely there may be bronchospasm. Severe, life-threatening anaphylactoid or nonallergic anaphylactic reactions are exceedingly rare (0.001 to 0.01 percent). In an accumulated series of 687,000 doses there were only five severe reactions. In another survey based on 20 million administered doses there were 55 cases of severe reactions. Fatal reactions to gadolinium chelate agents occur but are extremely rare.” |
|
|
risks for gadolinium based contrast media |
Patients with a prior reaction to GBCM have an eight-times increased risk of a subsequent reaction, which may be more severe than the first reaction. Other risk factors include asthma and other allergies, including to iodinated contrast media. Patients with these risk factors may have a risk of reaction of up to 3.7 percent. While there is limited information about the efficacy of preventive measures, suggested measures include using a different gadolinium compound and premedicating the patient with corticosteroids and antihistamines.GBCM are relatively contraindicated in pregnant patients. These agents pass through the placental barrier and enter the fetal circulation. They are then filtered by the fetal kidneys and excreted into the amniotic fluid where they may remain for a prolonged period to time. With prolonged presence of the chelate in the amniotic fluid, there is an increased potential of dissociation of the potentially toxic gadolinium ion. Although the risk to the fetus is unknown, due to the potential risk, GBCM should only be administered to pregnant patients in carefully selected situations when there is felt to be overwhelming benefit to their use. |
|
|
risk of NSF |
An additional consideration with use of GBCM is the risk of Nephrogenic Systemic Fibrosis (NSF). The ACR Contrast Manual defines NSF as “a fibrosing disease, primarily identified in the skin and subcutaneous tissues but also known to involve other organs, such as the lungs, esophagus, heart, and skeletal muscles. Initial symptoms typically include skin thickening and/or pruritis. Symptoms and signs may develop and progress rapidly, with some affected patients developing contractures and joint immobility. Death may result in some patients, presumably as a result of visceral organ involvement.” There are many continuing controversies and uncertainties regarding NSF and its relationship to the administration of GBCM. However, the combination of severe chronic kidney disease (Stage 4 [eGFR 15-29 ml/min/1.73 m2], Stage 5 [eGFR <15 ml/min/1.73 m2], and patients on dialysis) or acute kidney injury and a history of GBCM administration is found in most patients who develop NSF. Higher doses and multiple doses of GBCM are believed to increase the risk of NSF, but cases have occurred with single administration of a standard dose of GBCM. There is also controversy regarding the relative risk of the various available GBCMs. While there are confounding factors such as the relative market share of the agents and their use in higher doses, some agents do appear to have a higher risk of NSF, perhaps related to the likelihood of dissociation of the gadolinium ion from its chelate through a process known as transmetallation. Other postulated risk factors for NSF include metabolic acidosis or medications that predispose patients to acidosis, increased iron, calcium, and/or phosphate levels, high dose erythropoietin therapy, immunosuppression, vasculopathy, an acute pro-inflammatory event, and infection. Since the recognition of NSF and its relationship to GBCM administration, the incidence of GSF has fallen to close to zero primarily by avoiding or severely limiting administration of GBCA to patients with an eGFR <30 ml/min/1.73 m2 or with acute kidney injury. This requires screening of patients. The ACR Contrast Manual recommends obtaining an eGFR within six weeks of anticipated GBCM injection in patients with a history of renal disease (including a solitary kidney, kidney transplant, or renal neoplasm), over age 60, or with a history of hypertension or diabetes mellitus. If a GBCM must be administered, the lowest possible dose should be used and the agents with the highest association with NSF should be avoided. Consultation with the referring physician and informed consent from the patient are |
|
|
extravasation of contrast risks, rate |
Extravasation of intravenously administered iodinated contrast media can cause significant patient morbidity, although most patients have no significant sequelae. While extravasation can occur with hand injection or power injection and the frequency of extravasation is not thought to be related to the injection flow rate, the severity of extravasation is likely to be greater with power injection since a larger volume of contrast media is injected in a shorter period of time, and observation of the injection site may more difficult. The reported rate of extravasation with power injection for CT scanning ranges from 0.1 percent to 0.9 percent. Patient risk factors for the development of extravasation include inadequate ability to communicate (such as infants and children, the elderly, and patients with altered consciousness), severe illness and debilitation, and abnormal circulation in the limb to be injected. Risk factors related to the venous access include distal access sites (such as the hand, wrist, foot, and ankle), use of indwelling lines in place for more than 24 hours, and multiple punctures into the same vein. |
|
|
sequela of extravasation |
Immediately after extravasation of contrast, most patients will complain of swelling or tightness and/or stinging or burning pain at the site of extravasation. Edema, erythema, and tenderness may be found on physical examination. Extravasated contrast is toxic to the skin and surrounding soft tissues, possibly related to the hyperosmolality of the contrast. An acute local inflammatory response is initiated, which may peak in 24 to 48 hours. Two severe complications may occur. The most common is a compartment syndrome related to mechanical compression. The major risk factors for compartment syndrome are the volume of extravasated contrast and the capacity of the site of extravasation. The second severe complication is skin ulceration and tissue necrosis. The risk of a severe extravasation injury is increased in patients with arterial insufficiency or compromised venous or lymphatic drainage in the affected extremity. Severe injury is also more likely with larger volumes of contrast and extravasation into smaller anatomic compartments such as the dorsum of the hand, foot, or ankle. However, such injuries are rare. Wang et al., in a series of 442 extravasations of low osmolality contrast media in adults, reported only one case of compartment syndrome and three cases of skin blisters or ulcerations. |
|
|
treatment for extravasation |
There is no consensus on the most effective treatment for extravasation. Elevation of the affected extremity above the level of the heart to decrease capillary hydrostatic pressure may promote resorption of the extravasated contrast. Warm and cold compresses to the site of extravasation are both advocated by some radiologists with no clear evidence to favor the superiority of either approach. Some |
|
|
“On average, assuming a sex and age distribution similar to that of the entire U.S. population, the BEIR VII lifetime risk model predicts that approximately one person in 100 would be expected to develop cancer (solid cancer or leukemia) from a dose of |
“On average, assuming a sex and age distribution similar to that of the entire U.S. population, the BEIR VII lifetime risk model predicts that approximately one person in 100 would be expected to develop cancer (solid cancer or leukemia) from a dose of 100 mSv above background, while approximately 42 of the 100 individuals would be expected to develop solid cancer or leukemia from other causes.” |
|
|
conclusions from Brenner and Hall 2007 NEJM article regarding CT caused CA |
“about 0.4% of all cancers in the United States may be attributable to the radiation from CT studies.” Further, based on subsequent increases in CT usage, “this estimate might now be in the range of 1.5-2.0%.” This estimated risk is heavily dependent on age at time of exposure, |
|
|
which exams cause most radiation? |
The National Council on Radiation Protection and Measurements (NCRP) compared the ionizing radiation exposure to the US population and its relative sources in the early 1980s (during the early years of CT scanning) and in 2006. They showed a six-fold increase in total medical radiation exposure during that time. In the early 1980s, background radiation represented 83 percent of the total population exposure, with 15 percent from medical imaging. By 2006, the contribution from background had fallen to only 50 percent of the total, with no significant overall change in the amount of background radiation. Medical imaging rose to 48 percent of the total, and the number of CT scans performed rose from an estimated 3 million to 67 million. While CT scans accounted for 17 percent of all radiological and nuclear medicine imaging procedures in 2006, they contributed 49 percent of the total estimated medical dose. Radiographic and fluoroscopic studies, while accounting for 74 percent of all procedures, contributed only 11 percent of the total estimated medical dose. Nuclear medicine represented only 5 percent of total procedures but 26 percent of estimated medical dose. The remaining 14 percent of dose came from interventional procedures, which accounted for 4 percent of total procedures. |
|
|
An early and ongoing focus of the campaign was to encourage imaging professionals to take a pledge to “image gently.” They pledged: |
to make the image gently message a priority in staff communications this year; |
|
|
The Image Gently campaign wishes to provide those radiologists and technologists who work in predominantly “adult” hospital settings with the tools to decrease radiation by doing four simple things. |
First, reduce or “child-size” the amount of radiation used. Second, scan only when necessary. Third, scan only the indicated region. Fourth, scan once; multiphase scanning is usually not necessary in children. |
|
|
The Image Wisely pledge is: |
To put my patient’s safety, health, and welfare first by optimizing imaging examinations to use only the radiation necessary to produce diagnostic quality images; To convey the principles of the Image Wisely program to the imaging team in order to ensure that my facility optimizes its use of radiation when imaging patients; To communicate optimal patient imaging strategies to referring physicians, and to be available for consultation; To routinely review imaging protocols to ensure that the least radiation necessary to acquire a diagnostic quality image is used for each examination. |
|
|
The key messages of Step Lightly are: |
Step lightly on the fluoroscopy pedal; Stop and child-size the technique; Consider ultrasound or, when applicable, MRI guidance. |
|
|
Two dose index parameters are generally calculated and reported by CT scanners, |
the CTDIvol (CT Dose Index Volume) and the DLP (Dose Length Product). The definition and calculation CTDIvol are beyond the scope of this discussion. For helical CT scanning, the DLP equals the product of the CTDIvol and the scanning length. The unit of measurement for CTDIvol is the mGy (milliGray) and for DLP, mGycm. |
|
|
The ACR has also established three diagnostic CT reference values based on data from its CT Accreditation Program. |
The CTDIvol values are 75 mGy for CT of the head, 25 mGy for CT of the adult abdomen, and 20 mGy for CT of the pediatric (5 year old) abdomen. Facilities can compare their calculated values against these reference values and modify their scanning parameters as needed. |
|
|
Life support: Fundamental BLS principles Four Basic activities: |
Four Basic activities: Chest compressions Airway Breathing Defibrillation |
|
|
Life support: Fundamental BLS principles Change in sequence: |
1) Chest compression; 2) airway; 3) breathing Despite significant advances in prevention, cardiac arrest remains a very important public health problem and is the leading cause of death in the U.S. and other countries. In the U.S. and Canada, approx 350,000 people (1/2 in hospital) have cardiac arrest and receive CPR. Countless others have arrest without attempted resuscitation. High quality CPR improves a victim’s chances of surviving an arrest. |
|
|
Life support: Fundamental BLS principles Critical components of high-quality CPR: |
Critical components of high-quality CPR: Start compressions within 10 seconds of recognized cardiac arrest; |
|
|
Life support: Fundamental BLS principles Adult Chain of Survival: |
Adult Chain of Survival: Immediate recognition of cardiac arrest and activation of emergency response system; Early CPR with chest compressions; Rapid defibrillation; Effective advance life support; and Integrated post-cardiac arrest care. |
|
|
Life support: Fundamental BLS principles Pediatric Chain of Survival |
Pediatric Chain of Survival Prevention of arrest; Early high-quality bystander CPR; Rapid activation of EMS; Effective advanced life support; and Integrated post-cardiac arrest care. |
|
|
Single-rescuer CPR: A single rescuer should |
Single-rescuer CPR: A single rescuer should 1) activate ERS and begin compressions (100/min), followed by 2) opening the airway and then giving two breaths, and then 3) repeating the cycle after checking for peripheral pulse (carotid or radial). The carotid pulse should be assessed first, for between 5 and 10 seconds. The compression: ventilation ratio is 30:2. The rescuer should be sure the patient is on a firm surface to ensure circulation of blood flow from the heart. |
|
|
Airway There are two methods for opening the patient’s airway: |
Head tilt-chin lift Head tilt method: place one hand on victim’s forehead, push back with palm. Place fingers of other hand under bony part of lower jaw near chin. Lift jaw to bring chin forward. Jaw thrust Use the jaw thrust if any concern over a head or neck injury. The jaw is lifted, fingers placed under angle of jaw, lifting with both hands, without tilting the head. |
|
|
One rescuer CPR breathing |
One-rescuer CPR: position yourself at victim’s side, place mask on victim’s face, seal mask with both hands, perform a head tilt-chin lift to open airway, press firmly on mask to seal, and deliver air over one second, watching victim’s chest rise. Bag-mask devices are not recommended for single rescuer situation, but are useful in two-rescuer CPR. Even if you are supplying supplemental oxygen, still use one- second per breath for any method of delivery. |
|
|
breakdown of Two-rescuer CPR: |
Two-rescuer CPR: Rescuer #1 is at the victim’s side. He or she should conduct chest compressions, (two-inch compression, 100/minute), allow the chest to recoil after compression, and limit interruptions to < 10 seconds (compressions-to-breaths ratio of 30:2, count compressions aloud). Switch places every five cycles or two minutes, taking less than five seconds to switch places. Rescuer #2 is at the victim’s head. He or she should maintain an open airway using head tilt-chin lift or jaw thrust. The rescuer should then give breaths, watching for chest rise and avoiding excessive ventilation. Observe performance of chest compressions, offering suggestions for correct form. Switch duties every five cycles or two minutes. |
|
|
defibrillation set up |
Set-up Position the device at victim’s side, next to rescuer who will be using it. This allows the second rescuer to perform chest compressions while first rescuer attaches the pads and uses the AED controls. Power on the AED; Attach pads to chest-right upper chest and lower left chest below and lateral to heart (if chest is very hairy, may need to shave the chest for pad attachment); Older than eight years, use adult pads. If less than eight and pediatric pads available, use them; “Clear” the victim and analyze the rhythm; If AED states a shock is needed, make sure the victim is “cleared” of contact from others; Press SHOCK button (< 10 seconds from last compression much better prognosis for survival); If no shock needed, continue chest compressions and CPR; |
|
|
how does Pediatric CPR differ from adult? |
Pediatric CPR Differs from adult CPR.* If solo rescuer, deliver five cycles of CPR before activating EMR (emergency medical response) system. Check victim’s carotid or femoral pulse to assess circulation. If heart rate is < 60/min. with signs or poor perfusion, start chest compressions and breaths at 30:2 ratio (like adults). If a second rescuer appears, go to compression: ventilation ratio of 15:2. One may use one or two hands for chest compression on very small children. *In adults, sudden cardiac arrest occurs with oxygen content normal for the first few minutes, so compressions alone may be sufficient. In children, cardiac arrest often accompanies respiratory failure, so the oxygen level may be low to start. Therefore, a combination of compressions and breaths is important. |
|
|
what is rescue breathing and how is it done? |
Rescue Breathing When pulse present, but victim is not breathing, employ rescue breathing. Adults: one breath every five seconds; Infants/Children: one breath every three to five seconds; Both scenarios: give breath over one second; chest should visibly rise; check pulse every two minutes |
|
|
life support Relief of Choking |
Relief of Choking It is most important to distinguish mild from severe airway obstruction. If the victim has good air exchange, can cough forcefully, is wheezing between coughs, or can talk, it is a mild airway obstruction; encourage victim to cough and breathe on own. If mild airway obstruction persists, active the EMR; If the victim has no or poor air exchange, a weak or ineffective cough, makes a high-pitched noise while inhaling, become cyanotic/blue, is unable to speak, or clutches the neck with thumb and fingers, one must try to relieve the obstruction; Use the Heimlich maneuver in adults and children one year or older; In infants, use a combination of back slaps and chest thrusts alternating every five attempts. |
