Nursing care for women Nursing care for women undergoing Uterine Fibroid undergoing Uterine Fibroid EmbolisationEmbolisation

Jan Jackson BSc (Jan Jackson BSc (HonsHons), DMS, CMS, RN, SEN (UK)), DMS, CMS, RN, SEN (UK)

Head Nurse, Imaging Directorate, Hammersmith Head Nurse, Imaging Directorate, Hammersmith Hospitals NHS Trust, London, UKHospitals NHS Trust, London, UK

Hammersmith HospitalsNHS Trust

UFE UFE -- BackgroundBackground

First used in late 1970s to control postFirst used in late 1970s to control post--partum bleedpartum bleed

RavinaRavina et al (1995) published results on et al (1995) published results on treatment for UF diseasetreatment for UF disease

-- effective in controlling symptoms 80effective in controlling symptoms 80--94%94%

-- fewer complicationsfewer complications

-- over 7,000 women treatedover 7,000 women treated

UFE UFE -- ReputationReputation

Reputation of being Reputation of being ‘‘quick and safequick and safe’’

UF UF -- What are they?What are they?

Common growths in female population (20 Common growths in female population (20 --50%)50%)Smooth muscle in originSmooth muscle in originPredominantly benignPredominantly benignMay be associated with reproductive May be associated with reproductive disordersdisordersAsymptomatic fibroid do not require Asymptomatic fibroid do not require treatmenttreatment

UF UF -- Type of FibroidType of Fibroid

Intramural Intramural -- common and common and develops in the wall of develops in the wall of uterusuterus

SubserosalSubserosal -- develops develops under outside covering of under outside covering of uterusuterus

SubmucosalSubmucosal -- develops develops under the inner lining of the under the inner lining of the uterus and is lease uterus and is lease common and problematiccommon and problematic

UF UF -- Population affectedPopulation affected

Increased incidence between the ages of Increased incidence between the ages of 35 35 -- 4949

AfroAfro--Caribbean women higher riskCaribbean women higher risk

Generic and hormonal factorsGeneric and hormonal factors

UF UF -- SymptomsSymptoms

Abnormal vaginal bleeding (Abnormal vaginal bleeding (menorrhagiamenorrhagia))

Pelvic painPelvic pain

Pelvic pressure (large fibroid) on bladder, Pelvic pressure (large fibroid) on bladder, bowel, kidneys causing increases bowel, kidneys causing increases urination, constipationurination, constipation

Infertility, recurrent spontaneous abortion, Infertility, recurrent spontaneous abortion, prepre--term labourterm labour

UF UF -- DiagnosisDiagnosis

Physical exam (bimanualPhysical exam (bimanual--abdomen)abdomen)

UltrasoundUltrasound

MRIMRI

HysterosalpingogramHysterosalpingogram

CTCT

HysteroscopyHysteroscopy

UltrasoundUltrasound

UF UF –– Diagnosis (Diagnosis (ConCon’’tt))

Magnetic Resonance ImagingMagnetic Resonance Imaging

UF UF –– Diagnosis (Diagnosis (ConCon’’tt))

UF UF –– Diagnosis (Diagnosis (ConCon’’tt))

HystersalpingogramHystersalpingogram

UF UF -- Treatment optionsTreatment options

Symptoms management Symptoms management

Surgery Surgery

-- NSAIDNSAID

-- Hormone TherapyHormone Therapy

-- HysterectomyHysterectomy

-- MyomectomyMyomectomy

HysterectomyHysterectomy

UF UF -- Treatment options (cont)Treatment options (cont)

UF UF -- Treatment options (cont)Treatment options (cont)

Endometrial ablationEndometrial ablation

Thermal ablation of uterus fibroidThermal ablation of uterus fibroid

-- percutaneous insertion of laser fibrespercutaneous insertion of laser fibres

-- focussed USfocussed US

Uterine Fibroid Embolisation (UFE)Uterine Fibroid Embolisation (UFE)

Uterine Fibroid Uterine Fibroid Embolisation (UFE)Embolisation (UFE)

Less invasiveLess invasive

NonNon--surgicalsurgical

Performed by Interventional RadiologistsPerformed by Interventional Radiologists

Blood flow in the right and left uterine Blood flow in the right and left uterine arteries is occluded and the fibroids are arteries is occluded and the fibroids are deprived of their blood supplydeprived of their blood supply

Occlusion leads to necrosis and death of Occlusion leads to necrosis and death of the fibroidsthe fibroids

UFE UFE -- IndicationsIndications

Referred by gynaecologistReferred by gynaecologist

Symptomatic patients who have failed Symptomatic patients who have failed other therapy or do not wish to have other therapy or do not wish to have surgerysurgery

UFE UFE –– ContraindicationsContraindications

Coagulation disorder or other Coagulation disorder or other contraindication to angiographycontraindication to angiography

InfectionInfection

Other uterine pathology e.g. endometriosis, Other uterine pathology e.g. endometriosis, adenomyosis, canceradenomyosis, cancer

Patients who desire fertility and have Patients who desire fertility and have exhausted other alternativesexhausted other alternatives

UFE UFE –– Before ProcedureBefore Procedure

Pelvic US TA/TV or MRIPelvic US TA/TV or MRI

Excluding malignancyExcluding malignancy

Gynaecological examination Gynaecological examination -- reviewedreviewed

Discuss with interventional radiologistDiscuss with interventional radiologist

Procedure explained Procedure explained

Patient information leafletPatient information leaflet

ConsentConsent

UFEUFE

THE ROLE OF THE THE ROLE OF THE

IMAGING NURSEIMAGING NURSE

UFE UFE -- Patient preparationPatient preparation

Hammersmith Hospitals NHS Trust

Directorate of Imaging

HAVING AUTERINE FIBROID EMBOLIZATION

Information for patients

l

HAMMERSMITH HOSPITAL

RADIOLOGY DEPARTMENT

VASCULAR ROOM

Extension: 34943

Type: Time:

Yes No

NIDDM ________________ IDDM ____________________

Last BM __________ Time __________ On Metformin Yes No

Urinary catheter in place. IV access in situ.

To be administered 1/2 hr prior to procedure

Voltarol suppositoire 100mg

Only for female patients of child bearing age.

Date of last LMP _____ / _____ / _____

If LMP more than 10 days: Pregnancy Test Positive Negative

Fasting:

- No solid food for 4 hours prior to procedure. - Clear fluids: offered up to 2 hours prior to procedure, then nil by mouth.* The max. intake of clear fluids between 4 and 2 hours preprocedure is 1 litre only.

PLEASE COMPLETE INVASIVE PROCEDURE CHECKLIST AS WELL AS THE IMAGING ONE

Doc

umen

tatio

n

I.P. Checklist Completed Procedure discussed and documented in medical notes

Signature ___________________ Print __________________ Date __ / __ / __ Time ___:___

Ward

UTERINE FIBROID EMBOLISATION__________________________________________________

120 - 400

" Appointment times are approximate, and are subject to change, but we will keep you informed. Please inform us of any problem with this appointment."

Platelets

Surname

First name(s)

Hospital Number

Date of Birth

Appo

intm

ent

INRAPTT

Bloo

d Te

st

Please inform Imaging Department of any abnormal results.

Level Reference level< 1.2

22.0 - 29.0 secs

Date

Preg

. Sta

tus

Diabetic

Dia

bet.

Sta

tus

60 - 125 umol/l

F

astin

g

Creatinine9.0 - 12.0 secsPT

UFE UFE -- Patient preparationPatient preparation

Imaging nurse visits patient prior to Imaging nurse visits patient prior to procedureprocedure

AssessmentAssessment

Patient preparation instructionPatient preparation instruction

AnalgesiaAnalgesia

AntibioticAntibiotic

Nursing documentationNursing documentation

DIRECTORATE OF IMAGINGRADIOLOGY NURSING PROCEDURE RECORD

Date: ________________________________ Name: ___________________________________

Procedure: ____________________________ Hospital No.: ______________________________

Radiologist: ___________________________ D.O.B.: _____________ Age: _____________

Scrub Nurse: __________________________

Anaesthetist: __________________________ Sex: M / F Ward: ____________

Pre-procedure visit/information Yes / No Pre-procedure Assessment

Nurse__________________ Date __________ Name Band checked by: _________________

Blood results Consent obtained: Yes / No

Hb ________ WBC ______ Platelets ________ Pre-medicated: ________________________

PT_________ APTT ______ TT ___________ Allergies: _____________________________

Fib ________ INR ______ Other ___________ Nil by mouth from: ______________________

Language Spoken: English Other___________ Bilateral groin shaved: Yes / No / NA

Translator: Yes / No Translator Present: Yes / No Pedal Pulses: Rt ______ Lt ______

Relevant Medical History Relevant Drugs_______________________________________ _________________________________________

_______________________________________ _________________________________________

_______________________________________ _________________________________________

_______________________________________ _________________________________________

_______________________________________ Drug Sensitivities:___________________________

IV access _______________________________ Diabetic: Yes / No

_______________________________________ Blood Sugar Level: ________mmol/L

Infusions: _______________________________ Asthmatic: Yes / No

________________________________________ Infectious status: ________________________

TIME

Arrival in Radiology ______________________ Started: _____________ Finished: ______________

Ward Called: ____________________________ Collected ____________ Destination ____________

UFE UFE -- Hammersmith HospitalHammersmith HospitalPre Pre --procedureprocedure

Patient admits to wardPatient admits to ward

Seen by radiologist Seen by radiologist -- consent consent

Prepare for procedure e.g. NBM, shavedPrepare for procedure e.g. NBM, shaved

Collected by IA to ImagingCollected by IA to Imaging

Imaging nurse received patient and hand Imaging nurse received patient and hand over from ward nurseover from ward nurse

Check patientCheck patient

Medication Medication -- DiclofenacDiclofenac suppository 100 suppository 100 mgmg

UFE UFE -- Hammersmith HospitalHammersmith HospitalProcedure TechniqueProcedure Technique

Conscious sedationConscious sedationLocal anaesthesiaLocal anaesthesiaFemoral punctureFemoral puncturePelvic arteriogram performed Pelvic arteriogram performed Use of Use of microcathetersmicrocatheters and and guidewiresguidewires to to select uterine arteriesselect uterine arteriesPVAPVAFinal uterine arteriogramFinal uterine arteriogram

UFE UFE -- ArteriogramArteriogram

UFE UFE -- conscious sedation conscious sedation

AdultAdultSedation policySedation policyTo allow gastric emptying:To allow gastric emptying:

-- Solid food up to 4 hours prior to procedure.Solid food up to 4 hours prior to procedure.-- Clear fluids up to 2 hours prior to Clear fluids up to 2 hours prior to

procedure.procedure.-- Nil by mouth.Nil by mouth.

American Society of Anaesthesiologists Task Force on Sedation anAmerican Society of Anaesthesiologists Task Force on Sedation and Analgesia by nond Analgesia by non--anaesthesiologists (1996) Practice anaesthesiologists (1996) Practice guidelines for sedation and analgesia by nonguidelines for sedation and analgesia by non--anaesthesiologistsanaesthesiologists

UFE UFE -- PeriPeri--procedureprocedure

Conscious sedationConscious sedation

Pain managementPain management

-- pain assessmentpain assessment

Monitor vital signsMonitor vital signs

Comfort and reassuring patientComfort and reassuring patient

DocumentationDocumentation

UFE UFE -- Nursing documentation.Nursing documentation.PERI-OPERATIVE PROCEDURAL OBSERVATIONS

ECG, Blood Pressure, Pulse, Respiration, O2 Saturation, O2, Temperature and Medication Recordings

Date

Time

B 220L 210O 200O 190D 180

170P 160R 150E 140S 130S 120U 110R 100E 90

8070

P 60U 50L 40S 30E 20

100

RespirationO2 Sat %O2 L / MinECG Rhythm

DRUGSLidocaine % mlBuscopan mg

Glucagon mg

Fentanyl mcg

Hypnovel mg

Heparin units

ContrastBatch no

NURSING INTERVENTIONS

Intra Procedure Post Procedure Evaluation

Respiratory Self Ventilating O2 __________ L / minVia Mask Nasal cannula GA Intubated Ventilated

Self ventilating O2 __________ L / min for ______ hr

Chest X-Ray Checked

Cardiovascular Refer to observation chart Infusion: _______________________

---------------------------------------------------

Neurological Conscious levelAwake Drowsy Rousable Specify __________

Conscious levelFully awake Drowsy Orientated Other ________________________

Pain Analgesia Sedation Local Anaesthesia Refer to observation chart

Pain free Comfortable Pain scale 0 – 5: _________(1 = no pain, 2= mild, 3 = moderate, 4 =severe, 5 = unbearable)

Hygiene/Dressing Puncture site:

Femoral artery: Right Left

Jugular vein: Right Left

Puncture site ____________________

Pedal pulses Right Left

Drainage _______________________

Specimens taken_________________

Ultrasound guidance Fluoroscopy

Nursing Documentation_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Notes and property returned with patient Yes / No

Signature _________________________________ Print Name ____________________________

Date _____________________________________ Time _________________________________

Ward Nurse Signature _______________________ Print Name ____________________________

UFE UFE –– Pain Management During Pain Management During ProcedureProcedure

Pain assessmentPain assessment

MedicationsMedications

-- HypnovelHypnovel IV (IV (MidazolamMidazolam))

-- DiamorphineDiamorphine IVIV

-- ZofranZofran IV (IV (OndansetronOndansetron))

-- ParacetamolParacetamol infusioninfusion

UFE UFE -- Post procedurePost procedure

RecoveryRecovery

Pain managementPain management

AntiAnti--nausea medicationnausea medication

Activities Activities -- bed restbed rest

Education Education -- patients, ward nurse patients, ward nurse

UFE UFE -- Post procedure painPost procedure pain

Start shortly after 2nd uterine is occludedStart shortly after 2nd uterine is occluded

Worsen for 2 hours then plateau for 6Worsen for 2 hours then plateau for 6--8 8 hourshours

Improvement over next 12 hoursImprovement over next 12 hours

Improve over next several daysImprove over next several days

UFE UFE -- Post procedure Pain Post procedure Pain ManagementManagement

DiclofenacDiclofenac 50mg oral 8 50mg oral 8 hrlyhrly

TramadolTramadol 50mg oral 6 50mg oral 6 hrlyhrly

AntiAnti--emetic. emetic. ZofranZofran or or CyclizineCyclizine

UFE UFE -- Post Procedure SyndromesPost Procedure Syndromes

Pyrexia, nausea and vomitingPyrexia, nausea and vomiting

Pelvic painPelvic pain

Could last up to 24 Could last up to 24 -- 48 hours and up to 48 hours and up to

7 days7 days

Worse with large and multiple fibroidsWorse with large and multiple fibroids

UFE UFE -- ComplicationsComplications

Groin haematomaGroin haematomaPelvic painPelvic painUterine infection leading to hysterectomy Uterine infection leading to hysterectomy 0.5 0.5 -- 2%2%Fibroid impactionFibroid impactionPremature ovarian failure (menopause) 1 Premature ovarian failure (menopause) 1 --5%5%NonNon--target organ target organ ischaemiaischaemia2 reported deaths related to infection2 reported deaths related to infection

UFE UFE -- Discharge instructionsDischarge instructions

Femoral instruction site careFemoral instruction site care

Contact numberContact number

FollowFollow--up appointmentup appointment

Pain controlPain control

AntiAnti--emeticemetic

ShowerShower

Nothing in vagina for 2Nothing in vagina for 2--3 weeks (no sexual 3 weeks (no sexual intercourse, no tampon)intercourse, no tampon)

UFE UFE -- BenefitsBenefits

Treats all fibroid simultaneouslyTreats all fibroid simultaneously

Permanent infarction without Permanent infarction without regrowthregrowth

Minimally invasiveMinimally invasive

Preserve options for other therapiesPreserve options for other therapies

Effective in controlling bleedingEffective in controlling bleeding

Significant uterine volume reductionSignificant uterine volume reduction

Shorter recovery times Shorter recovery times

UFE UFE -- Benefits (cont)Benefits (cont)

Clinical success 80 Clinical success 80 -- 94%94%

Average reduction of fibroid volume 41 Average reduction of fibroid volume 41 --64%64%

Reported pregnancy post UFEReported pregnancy post UFE

UFE UFE -- NICE GuidelinesNICE Guidelines

July 2003July 2003

Remains uncertain over safety and Remains uncertain over safety and effectivenesseffectiveness

Both gynaecologists and radiologists are Both gynaecologists and radiologists are involved in the decision to carry out involved in the decision to carry out procedureprocedure

BSIR RegistryBSIR Registry

Systemic reviewSystemic review

UFE UFE -- ConclusionConclusion

Good short term resultsGood short term results

Require long term followRequire long term follow--upup

Need to carry out RCTNeed to carry out RCT

Effect on pregnancyEffect on pregnancy

ReferencesReferences

Walker, WJ Walker, WJ –– Uterine Artery Uterine Artery EmbolisationEmbolisation for Symptomatic Fibroids: for Symptomatic Fibroids: Clinical Result in 400 Women with Imaging FollowClinical Result in 400 Women with Imaging Follow--up up

Siskin, GP et al (2000) Siskin, GP et al (2000) –– Outpatient Uterine Artery Outpatient Uterine Artery EmblisationEmblisation for for Symptomatic Uterine Fibroids: Experience in 49 patients, JVIR 1Symptomatic Uterine Fibroids: Experience in 49 patients, JVIR 11:3051:305--311311

National Institute of Clinical Excellence (NICE) National Institute of Clinical Excellence (NICE) –– Uterine artery Uterine artery embolisationembolisation for fibroids, 2003for fibroids, 2003

Ryan, JM et al (2002) Ryan, JM et al (2002) –– Simplified PainSimplified Pain--Control Protocol after Uterine Control Protocol after Uterine Artery Artery embolisationembolisation, Radiology 2002;224:610, Radiology 2002;224:610--613613