Week 4 Flashcards
(89 cards)
1
Q
T-tube cholangiogram AKA
A
Post-operative cholangiography
2
Q
T-tube indications
A
- exclude biliary tract calculus where operative cholangiography was not performed / unsatisfactory results of operative cholangiography / reassessment for patency
- assess for biliary leaks post surgery
3
Q
Objectives of T-tube
A
- post-op assessment prior to removing T-tube after 7-10 days
4
Q
PTC
A
Percutaneous Transhepatic Cholangiogram
5
Q
PTC
A
Percutaneous Transhepatic Cholangiogram
6
Q
ERCP
A
Endoscopic Retrograde Cholangiopancreatography
7
Q
Pain Management of hepatobiliary system is done via __
A
Percutaneous Vertebroplasty
8
Q
Prelim films needed for postoperative cholangiography
A
Coned supine of right side of abdomen to check for kinking / slipped off
9
Q
Post-operative cholangiography procedure
A
- Patient lies supine & clamp drainage tube near patient & clean thoroughly with antiseptic
- Connect syringe with CM to tubing between patient & clamp
- Drain bile out from T-tube & inject CM under fluoroscopic control
- Tilt couch head down to visualize biliary system & feet down to visualize patency
10
Q
What spots films are taken for postoperative cholangiography
A
PA & oblique
11
Q
How to distinguish between bubble & stone in duct after CM injection for post-operative cholangiography
A
Using gravity; head / feet down and bubbles flow up & stones flow down
12
Q
Why should air bubbles be avoided during CM injection for post-operative cholangiography
A
They mimic residual stone
13
Q
Aftercare for post-operative cholangiography
A
- drain CM out of biliary system
- clean & repack tubing
- secure tubings using tape
- avoid kinking
14
Q
What is the difference between PTC & PTBD
A
PTC only involves CM injection to biliary system through skin whereas PTBD has an additional drainage procedure
15
Q
Drainage of obstructed biliary system is divided into __
A
Percutaneously (PTBD) invasive & Endoscopically (ERCP)
16
Q
External drainage of PTBD is performed __
A
After transheptic cannulation of biliary tree & PTC
17
Q
Internal drainage of PTBD is done after ___
A
Transhepatic / Endoscopic cannulation of biliary tree
18
Q
Indications for PTBD
A
- Jaundice
- ERCP is inappropriate or failed
19
Q
How does a patient get jaundice
A
Obstruction / infection / scarring / stones /carcinoma of bile ducts, liver, pancreas
20
Q
PTBD contraindications
A
- bleeding tendencies
- biliary tract sepsis
- suspected / known hydatid disease
21
Q
What are the 2 most common causes of bile duct obstruction
A
- tumors (carcinoma of pancreas/cholangiocarcinoma)
- stones in CBD
22
Q
Patient prep for PTBD
A
- NPO for 4 hours before procedure
- premedication using analgesia
- antibiotics before & 3 days after procedure
- IV fluids to avoid dehydration
23
Q
Fine needle used for PTBD
A
Chiba needle 22G / 16G angiocath
24
Q
Drainage catheters for PTBD
A
Pigtail 7/8 Fr
25
Equipment used for PTBD
- fine needle
- guide wires
- dilators
- drainage catheters
26
PTBD procedure
1. Patient lies supine / oblique
2. Take prelim films
3. Anesthetize entry site
4. USG guide to insert Chiba needl into liver during suspended respiration
5. Aspirate bile
6. Inject CM
7. Employ endoprosthesis through obstruction & drain bile
27
During PTBD, if the stricture cannot pass through stent or stone is too large, what should you do
- insert draining catheter at above stricture
- drain out from body
- arrange ERCP or open surgery
28
PTBD complications
- bleeding
- biliary & generalized sepsis
- bile leak with bile peritonitis / bile a
29
Biloma
Collection of bile within abdominal cavity
30
PTBD aftercare includes __
Flushing externally draining catheter with normal saline & exchange at 3 monthly intervals followed by antibiotics for 3 days minimum
31
Difference between T-tube & PTBD
T-tube is diagnostic and minimally invasive whereas PTBD is therapeutic and invasive
32
ERCP is becoming a primary method of ___
Direct cholangiography
33
What are the advantages of ERCP over PTC/PTBD
- can visualize & biopsy ampullary lesions
- demonstrates biliary tree & pancreatic duct
- greater therapeutic potential
- non-invasive
34
What are the benefits of ERCP
- specific treatment can be delivered
- no major surgery
- biopsies
- less discomfort
- non-invasive
35
ERCP objectives are __
- remove stones
- relieve jaundice
- perform balloon sphincter dilatation to drain bile from CBD to duodenum
36
ERCP is the preferred method to examine patients suspected of __
Bile duct stones / choledocholithiasis
37
Contraindications of ERCP
- oesophageal obstruction, varies, pyloric stenosis
- previous gastric surgery
- acute pancreatitis
- patient contraindicated for glucagon/buscopan
- severe cardiorespiratory disease
38
Patient prep of ERCP includes
- NPO 6 hours before procedure
- Stop certain meds such as aspirin before procedure
- antibiotic cover
39
ERCP is normally performed using a ___
Side viewing duodenoscope which allows other instruments to pass through to perform biopsies, inject CM or place stents
40
If ERCP is done in an endoscopy room, what is not needed?
Prelim films; just spot films by endoscopist
41
What prelim films are used for ERCP
AP & RPO of upper abdomen to check for opaque gallstones & pancreatic calculi
42
For ERCP, the throat is anesthetized using ___
4% Xylocaine spray & sedated using diazepam before & during procedure
43
ERCP procedure includes
1. Patient lies RPO & endoscope introduced till upper esophagus
2. Patient breathes easily as ampulla of Vater is located
3. Insert pre-filled CM catheter into ampulla & injected into CBD where spot films taken
4. Opacify biliary tree system
44
For ERCP of pancreatic system, what is the procedure
1. Patient lies RPO & endoscope introduced till upper esophagus
2. Patient breathes easily as ampulla of Vater is located
3. Insert pre-filled CM catheter into ampulla & injected till tail & first order side branches visualized
45
ERCP prone position is best for __
AP fluoroscopic imaging
46
ERCP semiprone position is best for __
Patients of certain habitus such as obese & respiratory compromise
47
ERCP supine position is best for
Patient that require closer airway monitoring during procedure
48
What are the film series of CBD
Prone = straight & both oblique
Supine = straigh,t, both obliques, trendelenburg, semi erect
49
Trendelenburg position for CBD ERCP is used to show __
Filling of intrahepatic ducts
50
Semi-erect (feet down) position is best used to fill ___
Lower ends of CBD & GB
51
For ERCP of pancreatic duct, the film series includes
Prone & both posterior obliques
52
Complications of ERCP are __
Acute pancreatitis, perforation, cholangitis
53
Aftercare of ERCP are __
1. NPO till sensation returns to pharynx
2. HR, BP, Temp monitored every 30 mins for 6 hours
3. Maintain antibiotics if biliary / pancreatic obstruction present
4. Study serum / urinary amylase if pancreatitis complication suspected
5. Inform patient that temporary, mild sore throat occurs after exam
6. Patients should not operate machinery 6 hours after exam
54
Indications of bronchoscopy
- bronchial tumor
- airway blockage
- narrowed airways
- inflammation & infections
- interstitial pulmonary disease
- identify cause of persistent cough / coughing blood
- spots seen in CXR
- vocal cord paralysis
55
Absolute contraindications of bronchoscopy
- acute respiratory failure with hypercapnia
- high grade tracheal obstruction
- cannot adequately oxygenate patient during procedure
- untreatable life threatening arrhythmias
56
What absolute contraindications can occur if patient is intubated & ventilated
Acute respiratory failure with hypercapnia
57
Relative contraindications of bronchoscopy are __
- recent MI
- unable to remain still during procedure
- uncorrectable coagulopathy
58
Objectives of bronchoscopy
- diagnose lung problem / infection / biopsy
- removal of mucus, FB, obstruction in airway
- place stent to open airway
-treat lung problem such as bleeding / narrowing / collapsed lungs
59
Patient prep for bronchoscopy
- NPO 6 hours before bronchoscopy & have IV access
- conscious sedation before exam
- pharynx & vocal cords anesthetized with nebulized / aerosolized lidocaine
- monitor BP, pulse oximetry, cardiac & supplemental o2 used
60
Bronchial washing includes __
Injecting saline through bronchoscope & aspirated from airways subsequently
61
Bronchial brushing includes ___
Brush advanced through bronchoscope to abrade suspected lesions to obtain cells
62
Bronchoalveolar lavage includes __
50 - 200ml of sterile saline infused into distal bronchoalveolar tree and then suctioned out to retrieve cells, proteins, microbes located at alveolar level
63
Local areas of pulmonary edema created by bronchoalveolarlavage may cause ___
Transient hypoxemia
64
Endobronchial biopsy obtains tissue samples from lesions seen in __
Airway lumen
65
Transbronchial biopsy obtains samples from ___
>= 1 site in lung parenchyma
66
Between endobronchial & transbronchial biopsy, which can be done without fluoroscopic guidance
Transbronchial biopsy
67
What is transbronchial needle aspiration
Retractable needle used to sample enlarged mediastinal lymph nodes / masses
68
Bronchoscopy complications include __
Bleeding, infection, bronchial perforation / spasm, laryngoaspasm, pneumothorax
69
Bronchospasm AKA
Airway irritation
70
Laryngospasm AKA
Vocal cord irritation
71
Bronchoscopy aftercare includes __
- patient oxygenated & observed 2-4 hours after procedure
- PA CXR TRO pneumothorax
72
What are the 2 primary indices of recovery
Return of gag reflex & maintenance of o2 saturation
73
When is feeding tube inserted
When patient cannot eat or drink adequately
74
If feeding is needed more than 30 days, what is used
Gastrostomy
75
Indications for feeding tube insertion / Gastrostomy
- oesophagus blockage due to cancer
- post acute CVA
- chronic progressive neuromuscular diseases
- dementia
- cystic fibrosis
- sedation / coma
- eating disorders
76
How to prepare patient for Gastrostomy
- alcohol / providone iodine swabs to skin
- glucagon to paralyze stomach muscles
- lidocaine for local sedation
- anaesthetic spray
- suction tubing for secretions & aspiration
77
Gastrostomy procedure starts with __
1. Patient lies supine & sedated with head tilted 30 degrees to prevent aspiration
2. Local anaesthetic spray into patient’s throat
3. Insert NGT
4. Inflate stomach with air
5. Clean upper abdomen & numb skin surface over stomach
6. Percutaneous puncture into stomach & insert 3 anchors / fasteners with sutures to hold stomach to skin
7. Guidewire used to dilate stomach to size of PEG & held in place with balloon
78
Gastrostomy aftercare includes __
- stomach & abdomen heals within 5-7 days with moderate pain managed with meds
- patient fed IV for 24 hours & feedings will begin when bowel sounds heard
- skin around Gastrostomy opening cleaned everyday
79
Purpose of vertebroplasty
Minimally invasive method to treat spinal compression # by injected cement into vertebral body to relieve pain & stabilize #
80
Vertebroplasty indications
- Osteoporosis #
- benign vertebral tumor (hemangioma)
- vertebral compression # involving osteonecrosis, non-union / cystic degeneration
81
Complications of vertebroplasty
- Cement leakage which causes cement to press onto spinal cord / nerves. Tiny pieces may enter bloodstream & organs, damaging them or causing death
- additional #
- leading / infection
82
Most important factor for success in Vertebroplasty is __
Visualizing needle placement & cement application
83
GA is only needed in patients who __
Cannot cooperate due to pain / agitated state
84
Vertebroplasty procedures start with __
1. Needle placed into vertebral body & cement injected with continuous lateral view monitoring especially at the posterior margin of vertebral body & epidural space
2. If extravasation occurs, procedure stopped
3. Post procedure control done under CT scan / spinal XR where patient remains motionless for 4 hours after procedure
85
What is the access path of lumbar spine
Transpedicular route
86
What is the access path of thoracic vertebrae
Intercostovertebral access
87
What is the access path of cervical vertebrae
Anterolateral approach
88
Which position is best for patients doing cervical, thoracic and lumbar?
Cervical = supine
Thoracic & lumber = prone
89
How is the 11G bone biopsy needl advanced through for vertebroplasty
Through pedicure with anterior, medial & caudal trajectory till anterior 2/3 of vertebral body reached
