Use of Smit Sleeve in cervix HDR brachytherapy

[madchemist89]

They know how to do it, but they aren't very good at it since they don't do it frequently. Patient is in the or for 20 minutes with a needle in their back trying to get CSF.

To the point of needing anesthesia for intracavitary, we used to do it all the time in the department with sleeve in place and pain meds.

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[evilbooyaa]

Yes, spinal/epidural anesthesia is hard to come by. It takes an experienced attending anesthesiologist.

MAC without intubation is easy to arrange. They just send a nurse-anesthetist 🙂

A little known secret is that T&O type of brachy, helped by a sleeve, does not require anesthesia

Giving a patient a norco and/or ativan and performing T&O is not going to comfortable for most patients to have optimal placement. Doing it under fentanyl/versed guided by the RO fine sounds fine until you have a patient that still can't tolerate or gets oversedated.

Refer to a place that does it properly (to me this is at least with moderate sedation with a spinal run by anesthesia, either MDA or CRNA) or don't do it at all would be my strong recommendation.

*EDIT* - Interesting to see where I was back in 2017. Since then, worked with T&R including the built in rectal retractor, fair # of interstitial and hybrid cases. I was such a RO Noobie nearly 5 years ago...

 

[seper]

Not only you don't need sedation to insert T&O, you don't even need stirrups. PM me, and I can set you up with some true masters of the craft to observe 🙂

 

[evilbooyaa]

Not only you don't need sedation to insert T&O, you don't even need stirrups. PM me, and I can set you up with some true masters of the craft to observe 🙂

Ah, yes I would love to be educated on a lack of patient comfort (or even proper positioning, some how) by a likely boomer, likely male, who minimizes the significant discomfort to most (if not all) of his patients of manipulating a cervix and stretching the vagina aggressively with the patient having no anesthesia.

Will we also be learning how to treat with LDR and 2D based planning in this course? Will the course expenses cover the therapy the patients will need afterwards?

I suppose I'm mostly being facetious, but I am just always surprised to see how dismissive some are of adequate anesthesia for these women during these procedures. Wonder if this has ever been studied by the ABS.

 

[taserlaser]

Yes, we do.

Fraction 1 is preceded by the procedure placing the smit sleeve in the OR and thus done with general anesthesia, ,mostly a laryngeal mask.
The patient are "cleared" by the anesthesia people around 1 hours after the procedure and so we take them from there to the MRI & CT, then do the planning and then deliver treatment. We need to give opioids often, because once the anesthesia fades off, they do feel pain. That's the downside of doing general anesthesia: once people are awake, it doesn't take long for them to feel the pain. And the first fraction is the most time consuming because of the MRI.

Fractions 2-4 are in spinal anesthesia.
We do not do an MRI for fractions 2-4, just a CT, so the time is shorter. But spinal anesthesia is excellent here, because the patients do not feel a thing basically.



I work in a big hospital, so resources are there. We have these mobile anesthesia teams that go from department to department for procedures (mostly they are occupied in the intervention radiology department) and we can book them. So they come with their whole equipment to out brachytherapy vault and take care of everything. Brachytherapy is considered one of the sweetest spots, apparently, among our anaesthesia people, because there is so little for them to do + we have chocolate. 🙂

I don’t do gyne brachy these days, but when I (recently) trained at my relatively high volume (Canadian) institution, we used similar to this with spinal each fraction, and MR first fraction and CT subsequent fractions. We are in the midst of upgrading our brachy suite so we can add MR and CT on rails though which will be very nice for workflow purposes. Never used a smit sleeve as far as I can recall, and just did weekly insertions.

Our anesthesiologists do not like us as much though. Less predictable end times to ORs for some interstitial cases, and far away from the tertiary ICU (though are connected, means far from code team help). Also for our prostate HDR we are not funded for enough OR time so they don’t get to bill for complete days. It’s a bit of a pain.