hemostasis: techniques and technologies · monopolar coagulation current flows from generator, to...
TRANSCRIPT
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Hemostasis: Techniques and
Technologies
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Funds Provided by
Continuing Education Provider
Disclaimer Statement:
These materials were developed by Pfiedler Education with funding provided by CONMED Corporation. No responsibility is assumed by Pfiedler or CONMED for any injury and/or
damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of the recommendations or ideas contained in the materials.
Because of rapid advances in the health care sciences, independent verification of diagnoses, medication dosages, and individualized care and treatment should be made. These
materials are not intended to be a substitute for the exercise of professional medical or nursing judgment.
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Learning Objectives
▪ Describe normal hemostasis
▪ Compare types of gastrointestinal (GI)
bleeds to potential diagnoses
▪ Differentiate variceal from nonvariceal
bleeding
▪ Discuss variceal treatment techniques
▪ Describe nonvariceal treatment techniques
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Anatomy and Physiology of the
Vascular System
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Vascular System: Anatomy and
Physiology
▪ System components:
▪ Heart
▪ Arteries
▪ Arterioles
▪ Veins
▪ Capillaries
▪ Carries blood throughout the body
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Hepatic Portal System
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Hepatic System
▪ Manages blood flow between the digestive tract
and heart
▪ Responsible for drainage of blood from capillaries
in:
▪ Spleen
▪ Stomach
▪ Intestines
▪ Pancreas
▪ Gallbladder
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Plasma (liquid)
Distributes nutrients
Removal of waste
Maintains body temperature
Platelets (Thrombocytes)
Prevention of blood loss
Assists in wound healing
White blood cells / WBC (Leukocytes)
Protection against foreign matter
& microorganisms
Red blood cells / RBC (Erythrocytes)
Oxygen transport
Carbon dioxide removal
Blood Biology
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Hemostasis
▪ Physiological process that stops bleeding
▪ Forms plug while maintaining blood circulation
▪ Activated within seconds
▪ Two main hemostatic components:
▪ Primary hemostasis
▪ Secondary hemostasis
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Normal Hemostasis
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Vasoconstriction
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Platelet Activation and Aggregation
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Fibrin Mesh
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Clot Dissolution
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Primary Hemostasis
▪ Platelets aggregate
▪ Platelets adhere to site of injury and
each other forming a plug
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Secondary Hemostasis
▪ Deposition of insoluble fibrin
▪ Forms a mesh
▪ Integrates into and around platelet plug
▪ Strengthens and stabilizes blood clot
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Gastrointestinal Bleeding
▪ Symptom of disease or trauma
▪ Originates from any area of GI tract
▪ Caused by pathologies such as:
▪ Hemorrhoids
▪ Ulcers
▪ Tears or inflammation in esophagus
▪ Diverticulitis, ulcerative colitis, Crohn’s disease
▪ Polyps
▪ Cancer
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Assess:
Circulatory Status
Comorbidities
Blood Tests
Normal heart rate/BP
Hgb> 100g/L
Age< 60 years
Unstable Hemodynamics
Significant comorbidities
Hgb< 100g/L
Age>60 years
General Admission
Elective Endoscopy
Intensive monitoring
Intensive nursing
Urgent endoscopy
Assess GI Bleed
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Gastrointestinal Bleeding
ANATOMICAL
LOCATION
TYPE OF BLEED POTIENTIAL
DIAGNOSIS
Esophagus Vomiting bright red
blood or coffee ground
material, black stool
Ulcer, Varices, Liver
disease
Stomach Vomiting bright red
blood or coffee ground
material, black stool
Ulcer, Gastritis,
Varices
Small Intestines Bright red/maroon
bleeding
Ulcer, AVMS,
Diverticula
Large Intestine Blood in stool Colon cancer, Polyps,
Colitis, Arterial-venous
malformations,
Diverticula
Rectum Bright red bleeding Hemorrhoids,
Diverticulitis, Tumors
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Categories of Bleeding
▪ Variceal:
▪ Bleeding in
esophagus,
stomach or rectum
▪ Dilated vein
▪ Nonvariceal:
▪ Bleeding in GI tract
▪ Cause other than dilated vein
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Variceal Bleeding
▪ Asymptomatic
▪ Diagnosed with bleed
▪ Patient in shock
▪ Hypotensive, blood loss
▪ Bleed 30%
▪ Rebleed 70%
▪ Mortality rate 10-20%
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Nonvariceal Bleeding
▪ Causes:
▪ Duodenal ulcer
▪ Peptic (gastric) ulcer
▪ Mucosal tear (Mallory-Weiss)
▪ Dieulafoy’s lesions
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Peptic Ulcer Disease
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Mallory-Weiss Tears
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Dieulafoy’s Lesion
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Endoscopic Treatment Techniques
Variceal:
▪ Rubber band
ligation
▪ Sclerotherapy
▪ Combination
therapies
Nonvariceal:▪ Injection therapy
▪ Thermal
▪ Mechanical
▪ Combination therapies
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Variceal Treatment Techniques
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Sclerotherapy
Intravaricel Paravariceal
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Sclerotherapy Technique
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Variceal Ligation
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Multi-shot Devices
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Band Ligation vs. Sclerotherapy
▪ Same efficacy
▪ Lower rebleeding rates
▪ Fewer deaths from rebleed
▪ Fewer complications
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Ligation Technique
▪ Endoscopically locate the varices
▪ Begin with the most distal varix and
proceed circumferentially to proximal
▪ Press ligating unit against varix
▪ Suction to “Red Out”
▪ Continue to suction
▪ Deploy band
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Band Ligation
▪ Swelling
▪ Sloughing
▪ Ulceration
▪ Healing
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Single Band Applications: Varices
& Hemorrhoids
• Rubber band ligation treatment
for hemorrhoids is quick
• Performed in less than 2 minutes
• Can be performed in the
physician’s office with minimal
post procedure recovery time
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Nonvariceal Treatment Techniques
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Injection Therapy
▪ Hypertonic saline
▪ Epinephrine
▪ Sclerosants
▪ Thrombin and fibrin
▪ Cyan-acrylate glues
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Injection Therapy Technique
▪ Locate the bleeding site
▪ Advance the needle out of
catheter
▪ Inject agent into mucosal
lining
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Thermal Coagulation
• Monopolar electrosurgery
• Bipolar electrosurgery
• Heater probe
• Argon plasma coagulation (APC)
• Lasers
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Monopolar Coagulation
▪ Current flows from generator, to active
instrument electrode, to patient, to
dispersive electrode
▪ Provides hemostasis
▪ Reduces the rate of recurrent bleeding
▪ In actively bleeding and in high-risk non-
bleeding patients
▪ Associated with greater tissue injury than
is the bipolar mode
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Bipolar Coagulation
▪ Delivers current though instrument
electrode▪ Only the tissue grasped is included in the circuit
▪ Dispersive electrode is not needed
▪ Limited to tissue in contact with the
instrument electrode
▪ Instrument electrodes
are coated ▪ Reduces tissue adhesion
▪ Provide more efficient hemostasis
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Bipolar Probes
Silver Gold
▪ Reduced tissue adhesions
▪ Higher conductivity (35%)
▪ Less resistance (28%)
▪ Lower conductivity
▪ Higher resistance
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Argon Plasma Coagulation
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Advantages of APC
▪ Gas is nontoxic
▪ Noncontact
reduces rebleed
▪ Depth to tissue is
limited
▪ Treats multiple
lesions
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APC Clinical Applications
▪ AVMs
▪ Watermelon stomach
▪ Post polypectomy bleeding
▪ Tumor bleed
▪ Post sphincterotomy bleed
▪ Peptic ulcer disease
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APC Techniques
▪ Tailor power
▪ Calibrate the distance/ tip
to tissue
▪ Avoid direct contact
▪ Avoid over insufflation
▪ Use isolated pulses and or
painting effect
▪ Purge catheter
▪ Use double channel scope
▪ Use patient return electrode
monitoring style
▪ Secure pad contact
▪ Check all connections
▪ Avoid inadvertent activation
▪ Follow monopolar
guidelines
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Endoscopic Doppler US
▪ Audible nonimaging probe
▪ Differentiates between arterial and
venous blood flow
▪ Used for acute peptic ulcer
hemorrhage
▪ Recent FDA review
▪ Reduces risk of rebleed
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Mechanical Therapy
▪ Endoscopic use of:
▪ Clips
▪ Balloons
▪ Bands
▪ Differs according to:
▪ Opening capacity
▪ Rotation ability
▪ Jaw width
▪ Cost
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Clinical Assessment
▪ Initial assessment:▪ History
▪ Physical examination
▪ Laboratory tests (CBC, chemistry, liver panel)
▪ Information should guide decisions:▪ Triage
▪ Resuscitation
▪ Therapy
▪ Diagnostic testing
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Clinical Assessment
▪ Potential symptoms:
▪ Dizziness
▪ Confusion
▪ Angina
▪ Severe palpitations
▪ Cold/clammy hands
▪ Physical examination:
▪ Laboratory test results
▪ Comorbidities
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Summary
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Questions?
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