- Email: [email protected]
Beware the Simple Case
Volume 24
’
Number 12
’
December
’
2013
for each individual patient in his or her lifetime could not be determined with absolute certainty. Previous MEs/ CPAs or comorbidities may confer higher risk for future events or mortality following such an event, which cannot be accounted for in the present study. In addition, algorithms for activating emergency responses can differ between institutions, and incidences and outcomes may vary between institutions. In conclusion, MEs/CPAs occur infrequently in patients undergoing IR procedures. However, it remains important for all IR personnel to be aware of the incidence of these events, of the relevant emergency alarm mechanisms, and of treatment algorithms in their institutions. Although the incidence of MEs/CPAs in patients undergoing IR procedures is low, 1-year mortality following these events is relatively high. The RR of MEs/CPAs is significantly higher in hemodialysis access interventions compared with other procedures, demonstrating the need for increased vigilance when caring for these patients, even during less invasive procedures such as catheter placement/exchange. Oversedation was the most frequently encountered complication related to an ME/CPA, highlighting the need for interventionalists to be well trained in recognizing signs of oversedation and managing its clinical consequences.
REFERENCES 1. Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011; 365:139–146. 2. Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intens Care Med 2007; 33:237–245. 3. Larkin GL, Copes WS, Nathanson BH, Kaye W. Pre-resuscitation factors associated with mortality in 49,130 cases of in-hospital cardiac arrest: a report from the National Registry for Cardiopulmonary Resuscitation. Resuscitation 2010; 81:302–311. 4. McCurd M, Wood S. Rapid response systems: identification and management of the “prearrest state.” Emerg Med Clin North Am 2012; 30:141–152.
1785
5. Jones D, Duke G, Green J, et al. Medical emergency team syndromes and an approach to their management. Crit Care 2006; 10:R30. 6. Buxton AE, Calkins H, Callans DJ, et al. ACC/AHA/HRS 2006 key data elements and definitions for electrophysiological studies and procedures: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing Committee to Develop Data Standards on Electrophysiology). Circulation 2006; 114:2534–2570. 7. Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990; 98:1388–1392. 8. Buist M, Bernard S, Nguyen TV, Moore G, Anderson J. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation 2004; 62:137–141. 9. Kause J, Smith G, Prytherch D, et al. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom—the ACADEMIA study. Resuscitation 2004; 62:275–282. 10. Kaufman JA, Reekers JA, Burnes JP, et al. Global statement defining interventional radiology. J Vasc Interv Radiol 2010; 21:1147–1149. 11. Abella BS. Not all cardiac arrests are the same. CMAJ 2011; 183: 1572–1573. 12. Cooper S, Janghorbani M, Cooper G. A decade of in-hospital resuscitation: outcomes and prediction of survival? Resuscitation 2006; 68:231–237. 13. Herlitz J, Bång A, Gunnarsson J, et al. Factors associated with survival to hospital discharge among patients hospitalised alive after out of hospital cardiac arrest: change in outcome over 20 years in the community of Göteborg, Sweden. Heart 2003; 89:25–30. 14. Brindley PG, Markland DM, Mayers I, Kutsogiannis DJ. Predictors of survival following in-hospital adult cardiopulmonary resuscitation. CMAJ 2002; 167:343–348. 15. Skrifvars MB, Castren M, Nurmi J, Thoren AB, Aune S, Herlitz J. Do patient characteristics or factors at resuscitation influence long-term outcome in patients surviving to be discharged following in-hospital cardiac arrest? J Intern Med 2007; 262:488–495. 16. Rueb GR, Brady WJ, Gilliland CA, et al. Characterizing cardiopulmonary arrest during interventional radiology procedures. J Vasc Interv Radiol 2013; 24:1774–1778. 17. Wang AYM, Lam CWK, Chan IHS, Wang M, Lui SF, Sanderson JE. Sudden cardiac death in end-stage renal disease patients: a 5-year prospective analysis. Hypertension 2010; 56:210–216. 18. Patatas K, Koukkoulli A. The use of sedation in the radiology department. Clin Radiol 2009; 64:655–663. 19. Arepally A, Oechsle D, Kirkwood S, Savader SJ. Safety of conscious sedation in interventional radiology. Cardiovasc Intervent Radiol 2001; 24: 185–190. 20. Johnson S. Sedation and analgesia in the performance of interventional procedures. Semin Intervent Radiol 2010; 27:368–373.
INVITED COMMENTARY
Beware the Simple Case Tony P. Smith, MD ABBREVIATIONS CPA = cardiopulmonary arrest, ME = medical emergency, RRT = rapid response team
From the Department of Radiology, Duke University Medical Center, Box 3808, Room 1502, Durham, NC 27710. Final revision received September 17, 2013; accepted September 23, 2013. Address correspondence to T.P.S.; E-mail: [email protected] The author has not identified a conflict of interest. & SIR, 2013 J Vasc Interv Radiol 2013; 24:1785–1787 http://dx.doi.org/10.1016/j.jvir.2013.09.008
This issue of the Journal of Vascular and Interventional Radiology (JVIR) contains two studies on cardiopulmonary arrests (CPAs) in interventional radiology. Both report patients undergoing procedures at two large academic centers, the Hospital of the University of Pennsylvania (1) and the University of Virginia School of Medicine (2).
1786
’
Commentary: Medical Emergency and Cardiopulmonary Arrest in IR
The two studies have similarities. The University of Pennsylvania study (1) is a 5.5-year review of more than 38,000 procedures and the University of Virginia study is a 6.5-year review of more than 36,000 procedures. Combined data from more than 75,000 procedures revealed a total of 35 CPAs (0.05%) in interventional radiology. Additionally, the University of Pennsylvania used the rapid response team (RRT) for an additional 43 medical emergencies (MEs). It is presumed that any ME becoming a CPA resulted in triggering the CPA team and is reported as such. For the present commentary, unless otherwise indicated, the topic is limited to CPA, which was defined identically in both studies (1,2). Oversedation was the most frequently reported complication (ie, ME) in the University of Pennsylvania study (1) and was treated entirely by the RRT. This speaks well for the utility of the rapid response concept in preventing an ME from progressing into a CPA. However, a 2010 metaanalysis (3) of 17 publications encompassing 1.3 million admissions concluded that, although the RRT model was very appealing, evidence supporting its function in decreasing in hospital deaths was lacking. In the University of Virginia study (2), only 4% of CPAs (n ¼ 1 patient) resulted from oversedation, although respiratory causes were noted in another 18%. However, there may be advantages in a setting such as interventional radiology in which the problem might be procedurally based, such as oversedation, and prompt management could prevent the ME from becoming a full CPA. Still, today, the most commonly used medications for conscious sedation in interventional radiology in the United States are fentanyl and midazolam (4). Trouble often ensues because of their relatively long half-lives, lack of individual predictability, and use in situations of short-lived intense discomfort in an otherwise relatively comfortable procedure. Interventional radiology procedures are certainly better suited for a short-acting medication such as propofol (5). However, its inherent limitation is, of course, the respiratory depression it causes, and, in most centers, it is limited to administration exclusively by anesthesia team members. The data from the two current studies (1,2) bring two important points to mind. First, be very wary of the “simple” cases. Problems may have been encountered with patients who were much more ill, but many of these are often being treated under different circumstances, including assistance from anesthesia and intensivists. The latter was pointed out in the University of Virginia study (2), in which only 4% (or one patient) was in the intensive care unit at the time. Finally, patients may be carrying directives for no resuscitative measures, and therefore any problems or even a death would not trigger a full CPA resuscitation. Second, having ready access to a qualified code team to immediately respond is crucial in saving the patient. One of the few proven points in advanced cardiac life support for successful patient resuscitation is the time to response. Additionally, basic life support and rapid
Smith
’
JVIR
defibrillation for ventricular fibrillation or pulseless ventricular tachycardia are the only two interventions that have been shown unequivocally to improve survival after cardiac arrest (6). Many interventionists would consider dialysis access procedures to be relatively simple, and these procedures are becoming widely performed today in outpatient access centers. Such centers are almost universally outside the confines of the hospital, with its many problems but also its dedicated CPA resuscitation teams. It is the presumption that all procedures in both these studies (1,2) were performed in the hospital setting and not at a freestanding access center. That being said, the most striking findings of these two studies pertain to CPA in dialysis recipients. The University of Virginia study (2) found a relative risk of 3.6 for CPA during dialysis access interventions, whereas the relative risk in the University of Pennsylvania study (1) was 5.5, including ME and CPA. This clearly points to the numbers of such dialysis cases now performed by interventional groups, although absolute quantities were not completely reported in either study. It also points to the frailty that may exist in the dialysis recipient, depending in part on the timing and quality of the most recent dialysis sessions. In the University of Pennsylvania study (1), dialysis access–related complications consisted of those related to catheter placement and exchange as well as fistulography and declotting procedures. In the University of Virginia study (2), dialysis shunt management and fistula declotting were reported separately from tunneled central venous access. It is unknown to what extent the tunnel accesses were dialysis catheter placements or even exchanges, but all are commonly done within the access center environment. Very little has been reported regarding complication rates in freestanding vascular access centers. Beathard et al (7) reported the success and complications of access procedures in dialysis recipients performed by the thenbudding field of interventional nephrology. The data were derived from 11 freestanding outpatient interventional facilities located in different regions of the United States. A total of 29 interventional nephrologists were involved in performing the procedures. The data were collected prospectively during the 2003 calendar year and totaled 14,067 cases encompassing the six most often performed procedural categories (tunnel catheter placement or exchange, fistula or graft angioplasty, and fistula or graft thrombectomy). The overall complication rate was 3.54%, but only 0.28% were considered major per Society of Interventional Radiology criteria (8). The highest percentages of complications were in fistula and graft declotting procedures, as also reflected in the studies reported here (1,2). For synthetic graft thrombectomy, complications occurred in 6.4% of cases, but only 0.62% were major. For native arteriovenous fistula thrombectomy, the complication rate was 7.89%, but the complications were classified as major in only 0.44% of
Volume 24
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Number 12
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December
’
2013
patients. None of the major complications for the entire study group were CPAs, nor were there any deaths reported intraprocedurally or in the pre- or postprocedural observation areas. The article by Beathard et al (7) is more than 10 years old, but many of the interventional nephrologists were new to the subspecialty and still reported no CPAs. It is unknown to what extent clinical assessment resulted in the dialysis procedures being performed in the hospital environment rather than at a dedicated outpatient access center. It may be presumed that patients undergoing dialysis access procedures are less healthy if such procedures are being performed within a hospital environment, but that is supposition. In the current studies (1,2), both institutions reported a majority of their events in inpatients, with only 18% (four of 23 patients) and 17% (two of 12 patients) starting as outpatients at the University of Virginia and the University of Pennsylvania, respectively. Survival to hospital discharge occurred in 50% (1) and 30% (2) of patients who experienced a CPA in the University of Pennsylvania and University of Virginia studies, respectively. Although these numbers sound grim on the surface, they are in fact within accepted ranges as reported in other large studies and noted by both groups of authors, hopefully debunking such offhanded comments as “it is better to code in the cafeteria than radiology…” Interestingly, there does seem to be a difference in CPA survival based on the location within the hospital where the event occurred. Skrifvars et al (9) studied CPA in Sweden and found interventional radiology to have one of the highest odds ratios for survival within the hospital following a CPA. Both these articles in the current issue of JVIR (1,2) add to the interventional radiology literature a piece that
1787
has been lacking. Further work should be carried out, and all of us should consider tracking the data, possibly even in a prospective manner, for our own internal review processes. As we move into an era of training more clinically oriented interventional radiologists and as we move away from within the hospital walls, directions in training and practice building must focus on the emergency care of our patients in the less insulated outpatient interventional setting. Beware the simple case.
REFERENCES 1. Nadolski G, Praestgaard A, Shlansky-Goldberg RD, et al. Medical emergencies and cardiopulmonary arrests in interventional radiology. J Vasc Interv Radiol 2013; 24:1779–1785. 2. Rueb GR, Brady WJ, Gilliland CA, et al. Characterizing cardiopulmonary arrest during interventional radiology procedures. J Vasc Interv Radiol 2013; 24:1774–1778. 3. Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med 2010; 170:18–26. 4. Haslam PJ, Yap B, Mueller PR, Lee MJ. Anesthesia practice and clinical trends in interventional radiology: a European survey. Cardiovasc Intervent Radiol 2000; 23:256–261. 5. Erden IA, Pamuk AG, Akinci SB, Koseoglu A, Aypar U. Comparison of two ketamine-propofol dosing regimens for sedation during interventional radiology procedures. Minerva Anestesiol 2010; 76:260–265. 6. Nolan JP, De Latorre FJ, Steen PA, Chamberlain DA, Bossaert LL. Advanced life support drugs: do they really work? Curr Opin Crit Care 2002; 8:212–218. 7. Beathard GA, Litchfield T, Physician Operators Forum of RMS Lifeline, Inc. Effectiveness and safety of dialysis vascular access procedures performed by interventional nephrologists. Kidney Int 2004; 66:1622–1632. 8. Sacks D, McClenny TE, Cardella JF, Lewis CA. Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol 2003; 14(suppl): S199–S202. 9. Skrifvars MM, Castren M, Nurmi J, Thoren AB, Aune S, Herlitz J. Do patient characteristics or factors at resuscitation influence long-term outcome in patients surviving to be discharged following in-hospital cardiac arrest? J Intern Med 2007; 262:488–495.
INVITED COMMENTARY
Dialysis Access Procedures in the Outpatient Setting: Risky? Aris Q. Urbanes, MD ABBREVIATIONS ASA = American Society of Anesthesiologists, CPA = cardiopulmonary arrest, ME = medical emergency From the Lifeline Vascular Access, 3 Hawthorn Parkway, Suite 410, Vernon Hills, IL 60061; Received and accepted October 8, 2013. Address correspondence to A.Q.U.; E-mail: [email protected] A.Q.U. is the vice president of Lifeline Vascular Access. & SIR, 2013 J Vasc Interv Radiol 2013; 24:1787–1789 http://dx.doi.org/10.1016/j.jvir.2013.10.010
I read with great interest the articles by Nadolski et al (1) and Rueb et al (2), which aim to enlighten the provider on the circumstances surrounding and leading up to a medical emergency (ME) or cardiopulmonary arrest (CPA) in patients undergoing interventional radiology procedures. The patients who appear to be at highest risk for development of these events are those undergoing dialysis catheter
’
Number 12
’
December
’
2013
for each individual patient in his or her lifetime could not be determined with absolute certainty. Previous MEs/ CPAs or comorbidities may confer higher risk for future events or mortality following such an event, which cannot be accounted for in the present study. In addition, algorithms for activating emergency responses can differ between institutions, and incidences and outcomes may vary between institutions. In conclusion, MEs/CPAs occur infrequently in patients undergoing IR procedures. However, it remains important for all IR personnel to be aware of the incidence of these events, of the relevant emergency alarm mechanisms, and of treatment algorithms in their institutions. Although the incidence of MEs/CPAs in patients undergoing IR procedures is low, 1-year mortality following these events is relatively high. The RR of MEs/CPAs is significantly higher in hemodialysis access interventions compared with other procedures, demonstrating the need for increased vigilance when caring for these patients, even during less invasive procedures such as catheter placement/exchange. Oversedation was the most frequently encountered complication related to an ME/CPA, highlighting the need for interventionalists to be well trained in recognizing signs of oversedation and managing its clinical consequences.
REFERENCES 1. Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011; 365:139–146. 2. Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intens Care Med 2007; 33:237–245. 3. Larkin GL, Copes WS, Nathanson BH, Kaye W. Pre-resuscitation factors associated with mortality in 49,130 cases of in-hospital cardiac arrest: a report from the National Registry for Cardiopulmonary Resuscitation. Resuscitation 2010; 81:302–311. 4. McCurd M, Wood S. Rapid response systems: identification and management of the “prearrest state.” Emerg Med Clin North Am 2012; 30:141–152.
1785
5. Jones D, Duke G, Green J, et al. Medical emergency team syndromes and an approach to their management. Crit Care 2006; 10:R30. 6. Buxton AE, Calkins H, Callans DJ, et al. ACC/AHA/HRS 2006 key data elements and definitions for electrophysiological studies and procedures: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing Committee to Develop Data Standards on Electrophysiology). Circulation 2006; 114:2534–2570. 7. Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990; 98:1388–1392. 8. Buist M, Bernard S, Nguyen TV, Moore G, Anderson J. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation 2004; 62:137–141. 9. Kause J, Smith G, Prytherch D, et al. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom—the ACADEMIA study. Resuscitation 2004; 62:275–282. 10. Kaufman JA, Reekers JA, Burnes JP, et al. Global statement defining interventional radiology. J Vasc Interv Radiol 2010; 21:1147–1149. 11. Abella BS. Not all cardiac arrests are the same. CMAJ 2011; 183: 1572–1573. 12. Cooper S, Janghorbani M, Cooper G. A decade of in-hospital resuscitation: outcomes and prediction of survival? Resuscitation 2006; 68:231–237. 13. Herlitz J, Bång A, Gunnarsson J, et al. Factors associated with survival to hospital discharge among patients hospitalised alive after out of hospital cardiac arrest: change in outcome over 20 years in the community of Göteborg, Sweden. Heart 2003; 89:25–30. 14. Brindley PG, Markland DM, Mayers I, Kutsogiannis DJ. Predictors of survival following in-hospital adult cardiopulmonary resuscitation. CMAJ 2002; 167:343–348. 15. Skrifvars MB, Castren M, Nurmi J, Thoren AB, Aune S, Herlitz J. Do patient characteristics or factors at resuscitation influence long-term outcome in patients surviving to be discharged following in-hospital cardiac arrest? J Intern Med 2007; 262:488–495. 16. Rueb GR, Brady WJ, Gilliland CA, et al. Characterizing cardiopulmonary arrest during interventional radiology procedures. J Vasc Interv Radiol 2013; 24:1774–1778. 17. Wang AYM, Lam CWK, Chan IHS, Wang M, Lui SF, Sanderson JE. Sudden cardiac death in end-stage renal disease patients: a 5-year prospective analysis. Hypertension 2010; 56:210–216. 18. Patatas K, Koukkoulli A. The use of sedation in the radiology department. Clin Radiol 2009; 64:655–663. 19. Arepally A, Oechsle D, Kirkwood S, Savader SJ. Safety of conscious sedation in interventional radiology. Cardiovasc Intervent Radiol 2001; 24: 185–190. 20. Johnson S. Sedation and analgesia in the performance of interventional procedures. Semin Intervent Radiol 2010; 27:368–373.
INVITED COMMENTARY
Beware the Simple Case Tony P. Smith, MD ABBREVIATIONS CPA = cardiopulmonary arrest, ME = medical emergency, RRT = rapid response team
From the Department of Radiology, Duke University Medical Center, Box 3808, Room 1502, Durham, NC 27710. Final revision received September 17, 2013; accepted September 23, 2013. Address correspondence to T.P.S.; E-mail: [email protected] The author has not identified a conflict of interest. & SIR, 2013 J Vasc Interv Radiol 2013; 24:1785–1787 http://dx.doi.org/10.1016/j.jvir.2013.09.008
This issue of the Journal of Vascular and Interventional Radiology (JVIR) contains two studies on cardiopulmonary arrests (CPAs) in interventional radiology. Both report patients undergoing procedures at two large academic centers, the Hospital of the University of Pennsylvania (1) and the University of Virginia School of Medicine (2).
1786
’
Commentary: Medical Emergency and Cardiopulmonary Arrest in IR
The two studies have similarities. The University of Pennsylvania study (1) is a 5.5-year review of more than 38,000 procedures and the University of Virginia study is a 6.5-year review of more than 36,000 procedures. Combined data from more than 75,000 procedures revealed a total of 35 CPAs (0.05%) in interventional radiology. Additionally, the University of Pennsylvania used the rapid response team (RRT) for an additional 43 medical emergencies (MEs). It is presumed that any ME becoming a CPA resulted in triggering the CPA team and is reported as such. For the present commentary, unless otherwise indicated, the topic is limited to CPA, which was defined identically in both studies (1,2). Oversedation was the most frequently reported complication (ie, ME) in the University of Pennsylvania study (1) and was treated entirely by the RRT. This speaks well for the utility of the rapid response concept in preventing an ME from progressing into a CPA. However, a 2010 metaanalysis (3) of 17 publications encompassing 1.3 million admissions concluded that, although the RRT model was very appealing, evidence supporting its function in decreasing in hospital deaths was lacking. In the University of Virginia study (2), only 4% of CPAs (n ¼ 1 patient) resulted from oversedation, although respiratory causes were noted in another 18%. However, there may be advantages in a setting such as interventional radiology in which the problem might be procedurally based, such as oversedation, and prompt management could prevent the ME from becoming a full CPA. Still, today, the most commonly used medications for conscious sedation in interventional radiology in the United States are fentanyl and midazolam (4). Trouble often ensues because of their relatively long half-lives, lack of individual predictability, and use in situations of short-lived intense discomfort in an otherwise relatively comfortable procedure. Interventional radiology procedures are certainly better suited for a short-acting medication such as propofol (5). However, its inherent limitation is, of course, the respiratory depression it causes, and, in most centers, it is limited to administration exclusively by anesthesia team members. The data from the two current studies (1,2) bring two important points to mind. First, be very wary of the “simple” cases. Problems may have been encountered with patients who were much more ill, but many of these are often being treated under different circumstances, including assistance from anesthesia and intensivists. The latter was pointed out in the University of Virginia study (2), in which only 4% (or one patient) was in the intensive care unit at the time. Finally, patients may be carrying directives for no resuscitative measures, and therefore any problems or even a death would not trigger a full CPA resuscitation. Second, having ready access to a qualified code team to immediately respond is crucial in saving the patient. One of the few proven points in advanced cardiac life support for successful patient resuscitation is the time to response. Additionally, basic life support and rapid
Smith
’
JVIR
defibrillation for ventricular fibrillation or pulseless ventricular tachycardia are the only two interventions that have been shown unequivocally to improve survival after cardiac arrest (6). Many interventionists would consider dialysis access procedures to be relatively simple, and these procedures are becoming widely performed today in outpatient access centers. Such centers are almost universally outside the confines of the hospital, with its many problems but also its dedicated CPA resuscitation teams. It is the presumption that all procedures in both these studies (1,2) were performed in the hospital setting and not at a freestanding access center. That being said, the most striking findings of these two studies pertain to CPA in dialysis recipients. The University of Virginia study (2) found a relative risk of 3.6 for CPA during dialysis access interventions, whereas the relative risk in the University of Pennsylvania study (1) was 5.5, including ME and CPA. This clearly points to the numbers of such dialysis cases now performed by interventional groups, although absolute quantities were not completely reported in either study. It also points to the frailty that may exist in the dialysis recipient, depending in part on the timing and quality of the most recent dialysis sessions. In the University of Pennsylvania study (1), dialysis access–related complications consisted of those related to catheter placement and exchange as well as fistulography and declotting procedures. In the University of Virginia study (2), dialysis shunt management and fistula declotting were reported separately from tunneled central venous access. It is unknown to what extent the tunnel accesses were dialysis catheter placements or even exchanges, but all are commonly done within the access center environment. Very little has been reported regarding complication rates in freestanding vascular access centers. Beathard et al (7) reported the success and complications of access procedures in dialysis recipients performed by the thenbudding field of interventional nephrology. The data were derived from 11 freestanding outpatient interventional facilities located in different regions of the United States. A total of 29 interventional nephrologists were involved in performing the procedures. The data were collected prospectively during the 2003 calendar year and totaled 14,067 cases encompassing the six most often performed procedural categories (tunnel catheter placement or exchange, fistula or graft angioplasty, and fistula or graft thrombectomy). The overall complication rate was 3.54%, but only 0.28% were considered major per Society of Interventional Radiology criteria (8). The highest percentages of complications were in fistula and graft declotting procedures, as also reflected in the studies reported here (1,2). For synthetic graft thrombectomy, complications occurred in 6.4% of cases, but only 0.62% were major. For native arteriovenous fistula thrombectomy, the complication rate was 7.89%, but the complications were classified as major in only 0.44% of
Volume 24
’
Number 12
’
December
’
2013
patients. None of the major complications for the entire study group were CPAs, nor were there any deaths reported intraprocedurally or in the pre- or postprocedural observation areas. The article by Beathard et al (7) is more than 10 years old, but many of the interventional nephrologists were new to the subspecialty and still reported no CPAs. It is unknown to what extent clinical assessment resulted in the dialysis procedures being performed in the hospital environment rather than at a dedicated outpatient access center. It may be presumed that patients undergoing dialysis access procedures are less healthy if such procedures are being performed within a hospital environment, but that is supposition. In the current studies (1,2), both institutions reported a majority of their events in inpatients, with only 18% (four of 23 patients) and 17% (two of 12 patients) starting as outpatients at the University of Virginia and the University of Pennsylvania, respectively. Survival to hospital discharge occurred in 50% (1) and 30% (2) of patients who experienced a CPA in the University of Pennsylvania and University of Virginia studies, respectively. Although these numbers sound grim on the surface, they are in fact within accepted ranges as reported in other large studies and noted by both groups of authors, hopefully debunking such offhanded comments as “it is better to code in the cafeteria than radiology…” Interestingly, there does seem to be a difference in CPA survival based on the location within the hospital where the event occurred. Skrifvars et al (9) studied CPA in Sweden and found interventional radiology to have one of the highest odds ratios for survival within the hospital following a CPA. Both these articles in the current issue of JVIR (1,2) add to the interventional radiology literature a piece that
1787
has been lacking. Further work should be carried out, and all of us should consider tracking the data, possibly even in a prospective manner, for our own internal review processes. As we move into an era of training more clinically oriented interventional radiologists and as we move away from within the hospital walls, directions in training and practice building must focus on the emergency care of our patients in the less insulated outpatient interventional setting. Beware the simple case.
REFERENCES 1. Nadolski G, Praestgaard A, Shlansky-Goldberg RD, et al. Medical emergencies and cardiopulmonary arrests in interventional radiology. J Vasc Interv Radiol 2013; 24:1779–1785. 2. Rueb GR, Brady WJ, Gilliland CA, et al. Characterizing cardiopulmonary arrest during interventional radiology procedures. J Vasc Interv Radiol 2013; 24:1774–1778. 3. Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med 2010; 170:18–26. 4. Haslam PJ, Yap B, Mueller PR, Lee MJ. Anesthesia practice and clinical trends in interventional radiology: a European survey. Cardiovasc Intervent Radiol 2000; 23:256–261. 5. Erden IA, Pamuk AG, Akinci SB, Koseoglu A, Aypar U. Comparison of two ketamine-propofol dosing regimens for sedation during interventional radiology procedures. Minerva Anestesiol 2010; 76:260–265. 6. Nolan JP, De Latorre FJ, Steen PA, Chamberlain DA, Bossaert LL. Advanced life support drugs: do they really work? Curr Opin Crit Care 2002; 8:212–218. 7. Beathard GA, Litchfield T, Physician Operators Forum of RMS Lifeline, Inc. Effectiveness and safety of dialysis vascular access procedures performed by interventional nephrologists. Kidney Int 2004; 66:1622–1632. 8. Sacks D, McClenny TE, Cardella JF, Lewis CA. Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol 2003; 14(suppl): S199–S202. 9. Skrifvars MM, Castren M, Nurmi J, Thoren AB, Aune S, Herlitz J. Do patient characteristics or factors at resuscitation influence long-term outcome in patients surviving to be discharged following in-hospital cardiac arrest? J Intern Med 2007; 262:488–495.
INVITED COMMENTARY
Dialysis Access Procedures in the Outpatient Setting: Risky? Aris Q. Urbanes, MD ABBREVIATIONS ASA = American Society of Anesthesiologists, CPA = cardiopulmonary arrest, ME = medical emergency From the Lifeline Vascular Access, 3 Hawthorn Parkway, Suite 410, Vernon Hills, IL 60061; Received and accepted October 8, 2013. Address correspondence to A.Q.U.; E-mail: [email protected] A.Q.U. is the vice president of Lifeline Vascular Access. & SIR, 2013 J Vasc Interv Radiol 2013; 24:1787–1789 http://dx.doi.org/10.1016/j.jvir.2013.10.010
I read with great interest the articles by Nadolski et al (1) and Rueb et al (2), which aim to enlighten the provider on the circumstances surrounding and leading up to a medical emergency (ME) or cardiopulmonary arrest (CPA) in patients undergoing interventional radiology procedures. The patients who appear to be at highest risk for development of these events are those undergoing dialysis catheter