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

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

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

Hammersmith HospitalsNHS Trust

UFE - BackgroundUFE - Background

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

Ravina et al (1995) published results Ravina et al (1995) published results on treatment for UF diseaseon treatment for UF disease

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

- fewer complications- fewer complications

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

UFE - ReputationUFE - Reputation

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

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

Common growths in female Common growths in female population (20 -50%)population (20 -50%)

Smooth muscle in originSmooth muscle in origin Predominantly benignPredominantly benign May be associated with May be associated with

reproductive disordersreproductive disorders Asymptomatic fibroid do not Asymptomatic fibroid do not

require treatmentrequire treatment

UF - Type of FibroidUF - Type of Fibroid

Intramural - common Intramural - common and develops in the and develops in the wall of uteruswall of uterus

Subserosal - develops Subserosal - develops under outside covering under outside covering of uterusof uterus

Submucosal - develops Submucosal - develops under the inner lining under the inner lining of the uterus and is of the uterus and is lease common and lease common and problematicproblematic

UF - Population affectedUF - Population affected

Increased incidence between the Increased incidence between the ages of 35 - 49ages of 35 - 49

Afro-Caribbean women higher riskAfro-Caribbean women higher risk Generic and hormonal factorsGeneric and hormonal factors

UF - SymptomsUF - Symptoms

Abnormal vaginal bleeding Abnormal vaginal bleeding (menorrhagia)(menorrhagia)

Pelvic painPelvic pain Pelvic pressure (large fibroid) on Pelvic pressure (large fibroid) on

bladder, bowel, kidneys causing bladder, bowel, kidneys causing increases urination, constipationincreases urination, constipation

Infertility, recurrent spontaneous Infertility, recurrent spontaneous abortion, pre-term labourabortion, pre-term labour

UF - DiagnosisUF - Diagnosis

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

UltrasoundUltrasound MRIMRI HysterosalpingogramHysterosalpingogram CTCT HysteroscopyHysteroscopy

UltrasounUltrasoundd

UF – Diagnosis UF – Diagnosis (Con’t)(Con’t)

Magnetic Resonance ImagingMagnetic Resonance Imaging

UF – Diagnosis (Con’t)UF – Diagnosis (Con’t)

UF – Diagnosis UF – Diagnosis (Con’t)(Con’t)

HystersalpingogramHystersalpingogram

UF - Treatment UF - Treatment optionsoptions Symptoms management Symptoms management

Surgery Surgery

- NSAID- NSAID

- Hormone Therapy- Hormone Therapy

- Hysterectomy- Hysterectomy

- Myomectomy- Myomectomy

HysterectomyHysterectomy

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

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

Endometrial ablationEndometrial ablation Thermal ablation of uterus fibroidThermal ablation of uterus fibroid

- percutaneous insertion of laser - percutaneous insertion of laser fibresfibres

- focussed US- focussed US Uterine Fibroid Embolisation (UFE)Uterine Fibroid Embolisation (UFE)

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

Less invasiveLess invasive Non-surgicalNon-surgical 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 - IndicationsUFE - Indications

Referred by gynaecologistReferred by gynaecologist Symptomatic patients who have Symptomatic patients who have

failed other therapy or do not wish failed other therapy or do not wish to have surgeryto have surgery

UFE – UFE – ContraindicationsContraindications

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

InfectionInfection Other uterine pathology e.g. Other uterine pathology e.g.

endometriosis, adenomyosis, endometriosis, adenomyosis, cancercancer

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

UFE – Before UFE – Before ProcedureProcedure

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 - Patient preparationUFE - Patient 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

App

oint

men

t

INRAPTT

Blo

od T

est

Please inform Imaging Department of any abnormal results.

Level Reference level< 1.2

22.0 - 29.0 secs

Date

Pre

g. S

tatu

s

Diabetic

Dia

bet.

Sta

tus

60 - 125 umol/l

F

astin

g

Creatinine9.0 - 12.0 secsPT

UFE - Patient preparationUFE - Patient preparation

Imaging nurse visits patient prior Imaging nurse visits patient prior to procedureto procedure

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 - Hammersmith UFE - Hammersmith HospitalHospitalPre -procedurePre -procedure

Patient admits to wardPatient admits to ward Seen by radiologist - consent Seen by radiologist - 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 Imaging nurse received patient and

hand over from ward nursehand over from ward nurse Check patientCheck patient Medication - Diclofenac suppository 100 Medication - Diclofenac suppository 100

mgmg

UFE - Hammersmith UFE - Hammersmith HospitalHospitalProcedure TechniqueProcedure Technique

Conscious sedationConscious sedation Local anaesthesiaLocal anaesthesia Femoral punctureFemoral puncture Pelvic arteriogram performed Pelvic arteriogram performed Use of microcatheters and Use of microcatheters and

guidewires to select uterine guidewires to select uterine arteriesarteries

PVAPVA Final uterine arteriogramFinal uterine arteriogram

UFE - ArteriogramUFE - Arteriogram

UFE - conscious sedation UFE - conscious sedation

AdultAdult Sedation policySedation policy To allow gastric emptying:To allow gastric emptying: - Solid food up to 4 hours prior to - Solid food up to 4 hours prior to procedure.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 and Analgesia by non-anaesthesiologists American Society of Anaesthesiologists Task Force on Sedation and Analgesia by non-anaesthesiologists (1996) Practice guidelines for sedation and analgesia by non-anaesthesiologists(1996) Practice guidelines for sedation and analgesia by non-anaesthesiologists

UFE - Peri-procedureUFE - Peri-procedure

Conscious sedationConscious sedation Pain managementPain management

- pain assessment- pain assessment Monitor vital signsMonitor vital signs Comfort and reassuring patientComfort and reassuring patient DocumentationDocumentation

UFE - Nursing UFE - Nursing documentation.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 / Min

ECG 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 – Pain Management UFE – Pain Management During ProcedureDuring Procedure

Pain assessmentPain assessment MedicationsMedications

- Hypnovel IV (Midazolam)- Hypnovel IV (Midazolam)

- Diamorphine IV- Diamorphine IV

- Zofran IV (Ondansetron)- Zofran IV (Ondansetron)

- Paracetamol infusion- Paracetamol infusion

UFE - Post procedureUFE - Post procedure

RecoveryRecovery Pain managementPain management Anti-nausea medicationAnti-nausea medication Activities - bed restActivities - bed rest Education - patients, ward nurse Education - patients, ward nurse

UFE - Post procedure painUFE - Post procedure pain

Start shortly after 2nd uterine is Start shortly after 2nd uterine is occludedoccluded

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

Improvement over next 12 hoursImprovement over next 12 hours Improve over next several daysImprove over next several days

UFE - Post procedure Pain UFE - Post procedure Pain ManagementManagement

Diclofenac 50mg oral 8 hrlyDiclofenac 50mg oral 8 hrly Tramadol 50mg oral 6 hrlyTramadol 50mg oral 6 hrly Anti-emetic. Zofran or CyclizineAnti-emetic. Zofran or Cyclizine

UFE - Post Procedure UFE - Post Procedure SyndromesSyndromes

Pyrexia, nausea and vomitingPyrexia, nausea and vomiting Pelvic painPelvic pain Could last up to 24 - 48 hours and Could last up to 24 - 48 hours and

up to up to

7 days7 days Worse with large and multiple Worse with large and multiple

fibroidsfibroids

UFE - ComplicationsUFE - Complications

Groin haematomaGroin haematoma Pelvic painPelvic pain Uterine infection leading to Uterine infection leading to

hysterectomy 0.5 - 2%hysterectomy 0.5 - 2% Fibroid impactionFibroid impaction Premature ovarian failure Premature ovarian failure

(menopause) 1 - 5%(menopause) 1 - 5% Non-target organ ischaemiaNon-target organ ischaemia 2 reported deaths related to infection2 reported deaths related to infection

UFE - Discharge UFE - Discharge instructionsinstructions

Femoral instruction site careFemoral instruction site care Contact numberContact number Follow-up appointmentFollow-up appointment Pain controlPain control Anti-emeticAnti-emetic ShowerShower Nothing in vagina for 2-3 weeks Nothing in vagina for 2-3 weeks

(no sexual intercourse, no tampon)(no sexual intercourse, no tampon)

UFE - BenefitsUFE - Benefits

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 - Benefits (cont)UFE - Benefits (cont)

Clinical success 80 - 94%Clinical success 80 - 94% Average reduction of fibroid Average reduction of fibroid

volume 41 - 64%volume 41 - 64% Reported pregnancy post UFEReported pregnancy post UFE

UFE - NICE GuidelinesUFE - NICE Guidelines

July 2003July 2003 Remains uncertain over safety and Remains uncertain over safety and

effectivenesseffectiveness Both gynaecologists and Both gynaecologists and

radiologists are involved in the radiologists are involved in the decision to carry out proceduredecision to carry out procedure

BSIR RegistryBSIR Registry Systemic reviewSystemic review

UFE - ConclusionUFE - Conclusion

Good short term resultsGood short term results Require long term follow-upRequire long term follow-up Need to carry out RCTNeed to carry out RCT Effect on pregnancyEffect on pregnancy

ReferencesReferences

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

Siskin, GP et al (2000) – Outpatient Uterine Artery Siskin, GP et al (2000) – Outpatient Uterine Artery Emblisation for Symptomatic Uterine Fibroids: Experience in Emblisation for Symptomatic Uterine Fibroids: Experience in 49 patients, JVIR 11:305-31149 patients, JVIR 11:305-311

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

Ryan, JM et al (2002) – Simplified Pain-Control Protocol after Ryan, JM et al (2002) – Simplified Pain-Control Protocol after Uterine Artery embolisation, Radiology 2002;224:610-613Uterine Artery embolisation, Radiology 2002;224:610-613