SIR 2024
Renal and GU Interventions
Brendan Cline, MD
Assistant Professor of Radiology
Duke University Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Brian P. Triana, MD, MBA
Resident Physician
Duke University Medical Center
Disclosure information not submitted.
Katie Radulovacki, BA
Medical Student
Duke University School of Medicine
Disclosure information not submitted.
Miriam Chisolm, BS
Medical Student
Duke University School of Medicine
Disclosure information not submitted.
Jon G. Martin, MD (he/him/his)
Assistant Professor of Radiology
Duke University Medical Center
Disclosure information not submitted.
James Ronald, MD, PhD
Associate Professor of Radiology
Duke University Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Charles Y. Kim, MD, FSIR
Professor and Chief of Interventional Radiology
Duke University
Financial relationships: Full list of relationships is listed on the CME information page.
Hemodialysis-dependent patients referred for angiographic evaluation of their dysfunctional arteriovenous access (“fistulagrams”) often have multiple risk factors for adverse events with sedation given frequent comorbidities, abnormal fluid status, and electrolyte derangements. Since outpatient-based labs are less-well equipped to manage sedation events, determining the optimal site of service for these patients is important. The purpose of this study was to characterize the frequency and risk factors of adverse events with moderate sedation in patients undergoing fistulagrams.
Materials and Methods:
A retrospective analysis was performed of 588 fistulagrams procedures performed between 2019-23 at a single academic medical center (337 males, mean age: 59.8). Demographics, labs, sedation medications, and comorbidities were recorded. Adverse events were defined as administration of reversal agents (naloxone and/or flumazenil), Rapid Response Team (RRT) activation, or cardiac arrest. Univariate logistic regressions were performed to calculate odds ratios (ORs).
Results:
Adverse events were identified in 14 (2.4%) out of 588 cases (399 unique patients) and consisted of 4 events with only reversal agents, 7 RRT activations, and 3 cardiac arrests. Despite the theoretically higher risk of sedation events in the ESRD population, this rate is in keeping with previously published rates of sedation events across all IR procedures.{1} The average midazolam and fentanyl doses utilized were 1.1 mg (range: 0-6 mg) and 126.2 µg (range: 0-500 µg), respectively. Adverse events were associated with a Charlson score of > 7 (OR = 5.6, p = 0.002), presence of metastatic disease (OR = 3.77, p = 0.029), and an increased platelet count (OR = 1.0062, p = 0.031). A trend of increased OR was noted with potassium > 5.2 (OR = 2.75, p = 0.012) and history of congestive heart failure (OR = 3.60, p = 0.10). The remainder of regressions were not statistically significant.
Conclusion:
Despite ESRD status, the rate of sedation-related complications in this large cohort undergoing AV access intervention was similar to previously published rates across all IR procedures. This suggests that in general, these procedures can be safely triaged to outpatient centers as ASCs and OBLs become increasingly utilized. The association of increased adverse events with high Charlson scores ( >7) warrants further investigation and could be used to triage higher-risk patients within this population to the hospital outpatient setting.