UFE in Freestanding Outpatient Center (Office Based Lab)

John C. Lipman, MD, FSIR

Atlanta, Georgia

John Lipman, M.D., FSIR

• Consultant/Advisory Board: Merit Medical

• Other: Educational Grant Support, Boston Scientific

Why OBL ?

• Patient Preference & Economic Pressures

• Patients prefer OBL to hospital:

• -Cleaner, easier/more convenient, less expensive, more personal care

• We prefer it:

• -Control the product, individualized service, much more efficient, don’t need hospital

Economic

• Hospital incentivized to shift care IP--OP

• Healthcare Cost & Utilization Project (HCUP) Barrett et al Jan 2016 brief #200

• -Compared Hospital Inpt vs. Outpt Ambsettings for 4 treatments for uterine fibroids

• -Shorter X (0.6 vs 2.3d) stays--- lower charges $25k v $28k (even much lower c OBL)

Results

• SIR 2008 Lipman J & Amir L • -514 consecutive UFE pts, 501 d’c/d same day,

13 following am• -No pt returned within 1 wk, no transferER• Lipman (unpublished) OBL opened 5/7/15• -439 (thru 3/31/16) consecutive UFE pts• -All d/c’d same day, no bounce backs, no

transfershospital

How? Perform UFE Outpatient• 1. Patient/Family Education (thorough consult, expectations,

what to call us, signed document)

• 2. Specific Pain Protocol

• 3. Physician availability (cell #, nurses call q 24)

• 4. Home support

Pain Post-UFE

• Pain following UFE

• -Severity of the pain unpredictable (Roth AR, Spies J JVIR 2000; 11:1047-52)

• -Cumulative effect of combination of opioid & NSAID (Parker RK Anesthesia 1994 80:6-12)

• -Anti-emetic also helpful

Pain Timeline Post UFE• Pain increase for ~2hrs

• (AMBULATORY)

• Plateaus for ~3-4 hrs

• (DISCHARGE)

• Decreases to a lower plateau over next 4-5hrs

• Decreases each day over the next week. (Kirsch R

Medscape Women’s Health 2002 Mar-Apr 7(2): 4)

Pain control• Possibilities:

• 1. (Spinal or epidural anesthesia) adds complexity, not felt necessary, ?chronic pain pt

• 2. Superior hypogastric nerve block

• 3. Transdermal fentanyl patch

• 4. IA Lidocaine

• 5. (Ibuprofen c embolic or ibuprofen loaded beads)

Superior hypogastric plexus block• Continuation of celiac & lumbar sympathetic plexuses.

Innervates pelvic viscera including uterus.• Spencer E Cliical & Periprocedural pain management for UAE. Semin Intervent

Radiol 2013 Dec; 30(4): 354-63.

• Rasuli P Superior hypogastric nerve block for pain control in outpatient UAE. JVIR 2004; 15: 1423-9.

• How to:

• 1. Place cath over bifurcation

• 2. 21g needle below umbilicus aimed @ L4/5 disc

• 3. Inject contrast: cephalocaudal “fan shape stain”

• 4. 10ml 0.25% bupivicaine mixed c 10ml NS

• Seizures (intravascular injection)

Superior hypogastric plexus block

Transdermal Fentanyl Patch• Indicated for chronic pain (?off label)

• Patch works for 72hrs

• Serious or life threatening hypoventilation can occur in pts who are not opoid-tolerant

• 25mcg and 50mcg

• Probably need 50mcg

Intrarterial lidocaine• Lidocaine mixed c contrast for runoffs, TACE, UAE

(750mg max dose)

• Keyoung JA (Spies) JVIR 2001 12(9):105-9

• -10ml 1% (200mg) in each UA pre-embo

• -Study terminated p 18pts, vasospasm

• Zhan S Eur Radiol 2005 15: 1752-6

• -6ml (2ml 2% & 4ml saline) (40mg) post embolization

• -No severe or very severe pain (no PCAs)

• -Pain scores sig lower for 1st 48 hrs

Ibuprofen

• Ibuprofen• 1. Mixing ketoprofen c PVA during embolization (Bilhom T & Pisco J

Pharmaceuticals 2010;3:1729-38)

• 2. Loading embolic c IB (Borovac, (Pelage J) J Controlled Release 2006

115(3):266-74)

• 3. Sustained release (Namur et al J Cont Release 2009 135(3):198-202).Sheep

model, therapeutic levels of IB in surrounding tissue up to 7d

What I Do

• Pre: Toradol iv, Scopolamine patch, Tylenol 1000mg iv

• During: Fentanyl/Versed (50-100mcg/2-4mg), dilaudidimmediately post for cramping

• Lidocaine 5ml 1%pf each UA

• Post Fentanyl iv,(Dilaudid/Robaxin im post),Tylenol 1000mg iv

• D/C: Oxycodone* (5mgq2prn,#15) & Toradol (10q6,)/Motrin (800q6) x5d, Zofran (4mg q6prn)/Phenergan (1pr and q8prn, #5).

Nausea• Pain and/or narcotics

• Compazine & Phenergan suppositories hard to find

• Zofran expensive and taken po (post discharge)

• Isopropyl alcohol (snifs of alcohol pads) Spencer K Isopropyl

alcohol inhalation as a treatment of post op nausea and vomiting. Plast Surg Nurs 2004; 24(4):149-54.

• -Works quicker than zofran (10’ v 30’)

• -Much cheaper than zofran

• -Can self-administer in transit or @ home

Summary: Outpatient UFE

• 4 components:

• 1. Need to thoroughly discuss expectations/plan for post-procedural care

• 2. Dedicated pain regimen

• 3. Physician/staff availability

• 4. Home support