Welcome, everyone. My name is Anne Mellon, and I'm a gynae-oncology clinical nurse consultant in Australia, and I'm also one of the co-chairs of the IGCS Nurses Working Group. I am also the president of the Cancer Nurses Society of Australia, and I want to wish everybody who is listening from Australia today Happy Inaugural Cancer Nurses Day. And to all the cancer nurses out there across the world, we celebrate and honour the work that all cancer nurses do for our patients today to improve outcomes. I would like to welcome you to today's webinar, Gynaecologic Brachytherapy, Fundamentals of Nursing Care. We are thrilled to have you with us today. Before we get started, I want to mention a few housekeeping items. There'll be ample time for discussion today, so we encourage you to submit your questions via the Q&A feature at the bottom of your screen. We will do our best to address as many questions as possible. Zoom closed captions are available in multiple languages at the bottom of your screen as well. A recording of this webinar will be available on the IGCS Education 360 Learning Portal tomorrow. Now, it is my honour to introduce my co-chair and co-moderator Chrissy Donovan. Thank you, Anne. I'm Chrissy Donovan, and I am an IGCS Nursing Work Group co-chair and an oncology RN from Long Island, New York in the US. It is my honour today to introduce today's speakers. Joining us are Kayla Kafka-Peterson, the Nursing Supervisor of Radiation Oncology at UCLA, and Dr. Pooja Venkat, the Assistant Clinical Professor of Radiation Oncology at UCLA. During this webinar, Kayla and Pooja will be discussing brachytherapy, a powerful treatment tool in gynaecologic cancer. While this treatment is well-established, resources for nurses and teams have been severely limited and have only recently started to be created. Pooja and Kayla will provide a physician and nurse perspective with an in-depth focus on nursing care for patients receiving gynaecologic brachytherapy. In addition, they will also discuss clinical factors in coordinating treatment schedules, bedside care during procedures, pain management and anesthesia considerations, and advice for nurses to train not only their patients, but other nurses, team members, and healthcare professionals throughout their facility for maximum success. Without further ado, let's get started. I will turn this webinar over to Kayla and Pooja. All right, thank you very much. We're just going to share our screen. Can you see our screen okay? Yes. All right. Good morning, good afternoon, and good evening, depending where everyone is. It's nice to be here today to do this webinar. It's a pleasure to be here. Thank you for having us. I'm going to get started. We have no disclosures today, and we have a number of objectives. My part in this webinar is going to be pretty brief. I'm here more as support and to give an overview of brachytherapy, which is something I love and specialize in. Kayla is going to do most of the work here. The first objective here is me, and the rest belongs to Kayla. I will introduce the role of brachytherapy and its applications for patients with GYN malignancies. Kayla will then jump in, and we'll look at core concepts of caring for GYN brachytherapy patients prior to the day of procedure, so looking at care coordination, patient prep, and pre-anesthesia needs. We'll look at key elements for caring for patients undergoing GYN brachytherapy during the day of the procedure, preoperatively, intraoperatively, and postoperatively. We hopefully will become familiar with multimodal pain management for GYN brachytherapy patients, which can be complex. We'll learn how to anticipate and handle various complications on the day of the procedure, including hematuria, vaginal bleeding, nausea, and vasovagal responses slash syncope. Understanding the need for development of competencies and core curriculum for brachytherapy nurses and other patient care providers at the bedside to ensure brachytherapy specialty training has been completed and documented. And finally, we'll understand how nurses can be integral to training colleagues throughout the healthcare system that are involved in the care of brachytherapy patients but may not be part of the immediate team. A lot to get through today, so we'll jump right in. So part one, brachytherapy for GYN malignancies. Every time I talk about brachytherapy, I like to start with our founder, Maria Sklodowska-Curie, more commonly known as Madame Curie. She developed the theory of radioactivity, and for this, received two Nobel Prizes, one in physics and one in chemistry. So that's actually the only person to have ever received Nobel Prizes in two different fields. She was really driven by the idea and the need to alleviate human suffering, and I think she would be proud of our field today if she could see us. Here in the picture, if my mouse works, you can see one of the first radiation applicators ever invented and used on a patient. Here you see a statue of Maria Curie outside the Warsaw Radiation Institute. There's actually a hole through her heart, courtesy of the Nazis during World War II. But she was very proud of her Polish heritage, and that's something we should acknowledge, and our Polish colleagues, I'm sure, are very proud and have continued her tradition with great insights and advances in brachytherapy. Thank you. Brachytherapy has a role throughout the body. We like to say we have treated everything from the top of the head to the bottom of the foot and everything in between. Today, however, we really are going to focus just on GYN cancers. Pretty much every GYN cancer can and has been treated with brachytherapy. I think the two most important cancers we use brachytherapy for are locally advanced cervical cancer and early-stage endometrial cancer, but we also treat inoperable endometrial cancer, locally advanced badger and vulvar cancers, all recurrent GYN cancers, and oligometastatic disease. There are many different types of brachytherapy and different words that may be less familiar to people, so we'll look at a few of them today. One is HDR versus LDR, intracavitary versus interstitial, and then something I like to teach my residents and students is that it's all about the uterus when you think about GYN brachytherapy as the implants and the procedures change a lot, whether there's a uterus or whether this is a post-hysterectomy patient. For HDR versus LDR brachytherapy, what does that mean? I'd like to point out that this has nothing to do with the total dose delivered. It's not high dose versus low dose. It's really about the dose rate, the amount of radiation that's given per unit time, and there's a lot of information on this slide, but what's important to remember is low-dose rate brachytherapy is delivered over days to months, whereas high-dose radiation is really given over minutes. With LDR, you have to implant applicators for days or radioactive seeds that can stay on the patient forever, and there can be complications with this. There's more radiation exposure to staff members. Patients are often in bed rest for long periods of time, increasing the risk of DVTs, PEs, pressure ulcers, and pain. There's also concern about applicator displacement, and then if you are doing a GYN-LDR implant, patients are often very isolated in a hospital room where staff don't necessarily feel comfortable taking care of that patient due to radiation exposure. HDR tends to be a little bit more patient and staff-friendly. There's actually no radiation to staff, which is amazing for us. We do often need to do multiple treatments. It's rare that we can deliver all the dose required in one treatment. Typically, it's a range from three to six treatments for most patients. It does take a lot of resources. You need an HDR unit. You need all these different transfer tubes and catheters and booths where you can actually treat the patient safely, as well as whatever procedure you're doing your procedures in, so it can take a lot of resources, but it's definitely worth the investment. Although pain, pressure ulcers, and PEs are less of a significant risk than LDR, but these are still significant risks for our HDR patients, and I know Kayla's going to address that more directly. I thought I'd jump into a case presentation to go over some of the different types of brachytherapy. This is one of my patients, a 67-year-old female with a FIGO2B squamous cell of the cervix. You can see the tumor right here in the cervix, right between the bladder anteriorly and the rectum posteriorly. On this sagittal MRI, you can see the small cervical tumor right in the middle of that cervix. This is vaginal gel, bladder, and rectum. Standard of care treatment for locally advanced cervical cancer is concurrent chemo radiation with a brachytherapy boost. I have some specifics about doses and fractionations here. What's very important is that we want to complete the treatment time very quickly. Historically, we wanted to complete it within 56 days. We have shortened that down to even 49 days. This takes an incredible amount of coordination, which I know we will be discussing. Really, what I know as a physician is this cannot be done by a physician alone. It takes a whole team, and nurses are critical to that. Brachytherapy is very important for this disease. It improves local control and overall survival when compared to external beam and chemotherapy alone. To me, it is a required part of the treatment. Going back to the case, this is the patient's external beam plan. You can see the cervix in the middle. In red is the prescription dose. As you go out, you get lower and lower percentage of doses. The blue is the 50% of the dose. You can see we've curved it around the rectum and around the bladder anteriorly. This is using an IMRT plan. We're treating lymph node areas like the external iliacs here and the internal iliacs back here. Then on the sagittal view, you can see the dose along the sacrum and covering the uterus, the cervix, and part of the vagina. We're here to talk about brachytherapy. Here are some brachytherapy options. For this patient, you could do an intracavitary or an interstitial implant. What is the difference here? An intracavitary implant is where we put applicators into cavities that are already existing. In this image here, you see a typical tandem and ovoid applicator. This is an intracavitary implant where this tandem goes through the cervical os into the uterus. These ovoids go through the vagina and sit right up against the cervix. You can see it here where these are the ovoids and this is that tandem. This is a very commonly used applicator for cervical cancer. What's a little challenging about this is the dosimetry it gives is fixed. We call it fixed geometry dosimetry because it's limited by the fixed applicator we're using. Over here, you see an interstitial implant where instead of using that fixed applicator, we put little tubes or catheters directly into the cervix. The tubes go from down here. Some go through the vagina. Others go through the perineum. We use ultrasound to guide them right into our tumor, into our cervix, and into our uterus. Here's a few more pictures. This is a very common intracavitary applicator called a tandem and ring. The tandem, once again, goes through that cervical os into the uterus and the ring sits up against the cervix. Here you see another tandem and ovoid depiction here. Here are some fancier applicators. These are a little newer. These are hybrid intracavitary slash interstitial applicators. I think this one is probably the newest and most complex. We'll take a look at that. This is a tandem and a ring, but that ring has holes through it, which you can put interstitial catheters through. Then they also have this template area back here that can sit up against the perineum, where you can put catheters through that too. This is a little more complex treatment, but it does allow you to control that dose and account for asymmetry of tumor. Then my preferred type of brachytherapy is interstitial implants. I like interstitial implants because I just feel like I have all the control I could possibly want and I tend to be a controlling person. You can see here, you can put all these little tubes wherever you want. It's a good thing. Good kind of controlling. We put all these tubes and I can fit all this dose right in between the bladder and the rectum. What's important to know is that along these tubes, we can treat at five millimeter increments for as short or as long as we want to, which allows us to really curve our doses and fit them into tight spaces. Going back to our patient, this is my patient's interstitial implant. It showed a small tumor, so I put just a few little tubes you can see here in black. Then in red here, you see the prescription dose fully covering our tumor. On the sagittal view, you can see that we were able to get full dose in between the rectum, the sigmoid, the bowel up here and the bladder. These are tight spaces near organs at risk, but you're really able to get good dose in with this technique. In follow-up, this is her three-month post-treatment PET CT. You can see this is her cervix with little fiducial markers that I put in, but there's no residual FDG uptake in that cervix. You can see that here that the cervix is not lighting up at all. She had a complete response to treatment. For follow-up of our patients, that three-month PET CT is very important. That's the first imaging study we do. What we're looking for is complete FDG resolution of the tumor, but that always goes along with physical exams. We will do physical exams, a pelvic exam every three months for the first two years. Then we can extend that out to every six months for years three through five. Then we will do a pelvic exam annually after that. After that first PET CT imaging is only done as indicated by exam or clinical side effects. I'm not going to go too into it right now unless we have time later, but just remember vaginal dilators for follow-up. Vaginal toxicity is avoidable and is something we should work to prevent. We do have a robust vaginal dilator protocol here at UCLA that we'd be happy to share. Moving on to endometrial cancer. Endometrial cancer is typically standard of care is going to be surgical resection and pelvic lymph node dissection. Radiation is often used in the adjuvant setting or for inoperable or recurrent disease. We'll skip all those nuances there and jump into our brachytherapy plan. This is a standard vaginal cylinder applicator that's used for early stage cervical cancer with intermediate or high-risk pathologic features. You can see the cylinder is placed into the vagina and the dose is delivered through that cylinder. Once again, it's able to be fit in between all these normal structures despite the tight space. The doses often used are here. My preference is six gray times five prescribed to the surface every other day. I find that has the least vaginal toxicity. We also do interstitial implants for recurrent endometrial cancers. This is one of my patients who had this big left vaginal cuff recurrence. We put some catheters in it, did a nice interstitial implant. You can see my target in red is fully covered by the prescription dose. On this image here, you see that left vaginal cuff fully covered, the rectum and the bowel here. Would you like to go back? I have just a comment real quick. I think this last slide, this is a good example why interstitial is so beneficial on this particular implant because of how far over you're able to reach. Very good point. It's so lateral here. There would be no way to cover this with an intracavitary brachytherapy applicator here would be a vaginal cylinder, which would just go directly in the middle here and would miss this completely. Really, in this case, an interstitial implant is your only option. Lastly, for me today, I wanted to share a vulvar case with you. I hate treating vulvar cancer because it causes so many symptoms for patients, but it actually is also very rewarding. This patient came to us and she couldn't even sit up. She was in so much pain. This was her tumor here. You can see it on the PET scan here. Just really large tumor. A lot of people probably would have recommended palliative radiation for this patient, but we decided to be aggressive. She only had disease here. We did chemo radiation followed by a brachytherapy implant. This was my implant. There are over 50 little catheters put directly into this tumor. The catheters need to be spaced about five millimeters apart or the dose will get too hot. That's why there are so many. This took one or two hours, probably. I think it was more than that. It was more than that. And this is the dose. You can see, I think it's best seen on this sagittal image. We treated this very large area to high dose. In green here is the prescription dose, but the 50% dose line is in white. That dose falls off so quickly. You're getting no dose to the rectum up here, no dose to the bladder. Really good dosimetry with this implant. And then after treatment, this is what her vulva looked like at the end of treatment three months after. This was all that was left. Her pain disappeared. She was able to walk again. On the PET scan, there was just a little bit of FDG avidity left over. So my friend and colleague actually took her to the OR and did a radical vulvectomy. And on pathology, there was actually no residual tumor. So I stress this case because sometimes we defer to palliative radiation because we don't think we can really control a tumor because of its size. But with brachytherapy, particularly interstitial brachytherapy, we are able to cover and treat effectively tumors no matter how big. And with that, I think I will pass it out to the main act today. Kayla, I'll take over now. Thank you, Dr. Venkat. I'm going to just make sure I can see myself in the view here. Yep, okay. And I will minimize that again. So thank you for that. I like starting this type of lecture with Dr. Venkat because so much happens from the physician's standpoint is why does this patient get vaginal cylinder? Why does this one need interstitial needles? And that's beyond what a lot of the nurses know. So I really like how you presented that and kind of show the different applicators and how you can only get to some lesions with interstitial needles. And even though a lot of centers may not be able to do as complex of a vulva implant as you did, it can be done. And we do get people from all over. So really an amazing treatment. And now we're going to dive into the nursing stuff. Nursing care before, during and after GYN brachytherapy. All right, we got a lot to talk about. So brachytherapy nursing, it is a wonderful challenge. It is definitely a challenge. Starting a brachy program can be overwhelming. And, but the challenge presents opportunity for growth. A lot of brachytherapy nurses, we pride ourself in being able to do just about anything from being an intra-op nurse. Even if we've never worked in the OR, we learn how to circulate these cases. Sterilization or high-level disinfection becomes part of our daily job. And we've never had to even think about that before. Care coordination. That's been one of my favorite parts about this role is as I've been here longer, I've gone from being just at the bedside to now coordinating the patient navigation, but also coordinating the service and equipment. And it really has really challenged me to use all areas of my nursing brain to my best ability. And how do you do it all? And how do you do it well? Brachytherapy nurses, again, we must become experts in many areas of nursing, including bedside nursing, pre-op, intra-op, post-op, outpatient care, sedation. And we have, I'm sorry, I just kicked you. Sorry, Dr. Venkat. We have all acuity levels from ambulatory to ICU level on our service. So the nurses here really have a very neat job. Many nurses also have responsibilities outside of brachytherapy, like patients undergoing regular radiation, regular external beam radiation therapy, and trying to manage being in brachytherapy, but also external beam can be really tricky, especially for new teams that are just starting to take on brachytherapy. Flexibility, self-discipline, autonomy, resilience, and communication are critical for success as a brachytherapy nurse. So it is a specialty. There's no perfect guide for how to do this. Every team and facility does vary somewhat, but specific knowledge, it's very technical. It needs to be mastered for us to be able to take care of these patients. It is definitely a nursing specialty. It's something that you have to be taught. It's not really that intuitive where you can just figure it out. You either understand the concepts or you don't, and that's where it's really important that we train each other. So historically, for 100 years, brachytherapy has been around a long time. There's been very few resources that have existed for how to be a bedside nurse for these patients. Most of the material that exists is for physicians and physicists to learn how to actually do this treatment, because of course their part is incredibly important, but there's not a lot on once the implant's in, what do we do with them? How do we take care of them? What pain control methods are they? What do we do if there's a lot of bleeding in the bladder and they're throwing up, but you can't sit them up? Like all of these types of things, there's really no guide for that. And historically, it's been up to each team to train their staff and track their progress. And while this is great, it also makes it very isolated and you can't really develop best practices because every team's kind of on their own. So this is something that we're working on changing. Nurses really can be the center of education for brachytherapy, both within their teams and outside of their teams. And it's really important. A lot of our patients go throughout the healthcare system. They might be in a main OR if we don't have ORs on site. So you have to train the OR staff or the inpatient staff to take care of them as well. And I'll talk about this in a little bit, but it's really important that we do formal education with those areas and don't just rely on one-to-one handoff because that's not sustainable and you will have errors occur. So the brachytherapy nursing role does vary. Different teams look different. Some teams, like our team, we practice head-to-toe brachytherapy. A lot of teams will practice just prostate or just GYN. So it really is targeted, what the nurses do is targeted to that service. So some GYN brachy patients will require anesthesia, such as the interstitial catheter patients, the tanamen ring, tanamen ovoid, usually need some level of moderate sedation or light anesthesia, and then regular vaginal cylinders, they usually don't need anesthesia, but what you practice will determine how that looks for your service. And then some facilities will require care coordination to be done by a nurse. Other facilities will have a different arrangement. A lot of the new teams that I work with, the physicians take this on and it gets to a point where they're getting so busy that they have to figure out how do you hand it off over to a nurse? And we have education now available on that as well. Some facilities will also have the procedure room within radiation oncology, where you're basically like a little mini surgery center. And then other facilities do not have a procedure suite on site. So they have to use the surgery center or an inpatient OR or theater, I know is they use a lot outside the U.S. And then different facilities have a different setup and that will really shape how your team looks. It's important to know that brachytherapy teams do treat various body sites, but again, for the purpose of today's lecture, we're gonna focus on GYN specifically. Which is the most important. I actually do agree with that. Especially with cervical cancer rates just skyrocketing worldwide. I really feel like out of all the type of brachytherapy we do, I do think this is the most important and most critical right now. I think we agree very strongly on that. It is part of best practice for almost every type of gynecologic cancer, especially cervix. So it saves lives for sure. So again, just kind of review the applicators. So interstitial needles, that's going to be your highest level of nursing care. You're going through the tissues. There's going to be a higher chance for bleeding, probably a higher chance of pain all the way to vaginal cylinder on the end, which does not puncture anything. Not to say it's comfortable, but it goes into an existing cavity. So very often patients do not need anesthesia for that, but they still need nursing care and they still need a lot of love because it's still an uncomfortable procedure. And then in the middle is tandem and ovoid or ring. We don't do a lot of this. I know you have in the past, but I know the care is very similar to interstitial needles, positioning, and they need some pain control as well. So just kind of a review of those applicators. So care coordination before the brachytherapy, there's a lot that goes into making sure that the procedure can happen, that we don't get canceled, that the patient is in as good of shape as they can be for it, and that the timing is right. And this is something that can be owned by nurses. And this is something that I'm fortunate is kind of a core piece of my job and probably the part of my job I really enjoy a lot is the actual logistics of coordinating these patients' treatments, their schedules, working with our front desk on insurance authorizations, and making sure their labs are okay. We'll get into all of this, but there's so many moving parts that it's almost like a puzzle to make sure that this all lines up okay. So everything starts with the pre-procedure consultation. This is where Dr. Venkat or our other physicians will meet with the patient and determine brachytherapy is gonna be part of their care plan. We treat some of these patients with chemo RT here in the department for the regular radiation followed by brachytherapy with us. And then we also get a lot of patients from other hospitals that are treated external beam elsewhere that then come to us for the brachytherapy. So we will meet them at different points along their care spectrum, but we try to get them as early as possible to make sure that we can meet those treatment deadlines. So once the physicians see the patient, they will place orders for how many treatments they want and what type and what adjuvant therapies will be happening. Are they undergoing external beam beforehand, which is the case often, plus or minus chemotherapy. Most of the time, the chemotherapy is for cervix and vaginal patients. Don't see it as much with endometrial though, right? Typically, chemotherapy is often used for endometrial, but often not concurrently. Not with our brachy, yeah. But most of the time cervix and vaginal almost always they're on their own chemotherapy. And then vulvar. What about? Yes, often with vulvar. Yeah, we don't have a high volume of vulvar, but when we get them, they're very, I feel like they're very unique. Each one is so unique. But yeah, a lot of chemotherapy to keep in the back of our minds. And the patient education starts at consult and then continues for pre-procedure, the day of the procedure, and then after discharge. And some types of GYN brachy, again, can be done without sedation, like a vaginal cylinder. Others will require pain medication or full sedation or anesthesia. And knowing this will help the nurses in the team determine what is needed to get the patient ready. If they're getting anesthesia, they may need pre-op anesthesia clearance. If they're not getting anesthesia, you don't have to worry about that. So that'll help you determine your next steps. So brachytherapy care coordination, nurses can do a lot. We can do the actual care coordination, coordinating with the chemo schedules. We don't give chemotherapy. I've never given chemotherapy, but I know if they are on it. And then we usually will have them hold it just prior to brachytherapy. I will be watching their external beam radiation therapy plan as they're progressing through that, making sure they're not missing their treatments, making sure that our brachytherapy dates are synced up with their last day of external beam to start shortly thereafter. And if they're, you know, let's say they get hospitalized during EBRT, then that's gonna affect their brachytherapy dates and just really keeping tabs on these patients as they progress through often, you know, four or five weeks of external beam treatment. Surgery, sometimes we, you know, for vaginal cylinders, they may have surgery and then Dr. Venkat will let me know when she wants the brachytherapy to start. So trying to just time that. And then we have to do prep instructions, the bowel prep and diet prep before each procedure for the interstitial and for tanamen ring, tanamen ovoid. For vaginal cylinders, they don't need to do the same prep. Anticoagulation hold, if they're getting anesthesia, the GIPGLP-1 receptor agonist hold for anesthesia. Anticoags, we hold these for tanamen ring and ovoid, and we hold these for interstitial needles, but we do not hold them for vaginal cylinder. And then the GIPGLP-1 receptor agonist, this is the new drugs that are being used a lot for diabetes, but for weight loss. All of the brand names you're hearing now, you know, Monjaro and Ozempic and a whole bunch of semaglutide, which I know I think is Ozempic. All of those do have implications for anesthesia and they need to be held or anesthesia will probably not give anesthesia. Same for moderate sedation. So if they give them as an injection, we hold it for a week. And if they give it as oral medication, we have to hold it for a day. So we have to watch for those so we don't get canceled in the pre-op area. And then we also have to teach patients what to expect. There's a lot going on. It's a bizarre treatment that we have to, the more we kind of educate them and help them know, you know, there's gonna be phases of the day, you're gonna start in the procedure room, then this'll happen and this'll happen. Usually it helps put them at a little bit more ease. If anesthesia is needed, then I will do a pre-op screening. If there's any anesthesia concerns, any team communication, I'll make sure that that happens so we can have a plan ahead of time if we have a very complex patient. So the preoperative pre-anesthesia workup, this is very similar. A lot of different institutions have very similar guidelines. For us, it's based on the national pre-anesthesia workup guidelines through the American Association of Anesthesia, anesthesiology, I believe. And it's a combination of a pre-op physical from their primary care physician with some labs, complete blood count, metabolic panel, and coagulation studies, a 12 EDKG usually within six months, and then a physician's exam note. If they have cardiac history, we'll have them get cardiac workup as well. This may include additional workup if other comorbidities exist, such as cardiac, or if they are a transplant patient, we have to notify our transplant team, even though we're not going anywhere near that organ, there's these little things that we do have to do ahead of time. And then nurses can help facilitate coordination of these items if required by the facility. Then we can also help watch the results of these come in prior to the brachytherapy, and we'll let the physicians know if anything is significantly out of range. So risk stratification for anesthesia, in the last 10, 15 years, at least in the US, but I'm assuming worldwide, there's been a lot of push to do things outpatient. And with that comes the question of who should have anesthesia in an outpatient setting, or who should stay in kind of the main OR setting for places that have both. Because when you're in the outpatient setting, it's usually less intensive procedures, healthier patients with maybe less comorbidities, lower risk procedures. But when patients have a lot of comorbidities, it may not be the safest venue for them because there's a little bit less support. So anesthesia in a lot of facilities will have a risk stratification protocol we have to follow for who can safely be done outpatient, who needs to go inpatient, and our facility does have that. Even if this doesn't apply to your area, you still want to at least be on the lookout for patients that have these things, have these conditions, because it can increase their risk of complications during anesthesia or sedation. So it's still good to know these things, even if there's not a venue selection that has to happen. So example of things to watch for, significant cardiac conditions such as heart failure, especially with an EF less than 30, 35%, aortic valve stenosis, severe arrhythmias like AFib with the RVR, recent MI with stents or without stents. A lot of patients too that have had recent stents cannot come off anticoag for a certain amount of time. So sometimes, or if they have a fresh DVT, we see that not uncommonly, especially in our GYN population. So before we can just pull them off of anticoags, we have to make sure they can come off and that they can do so as safely as possible. And for the patients with the new DVT, we may arrange for them to have like a IVC filter placed prior to taking them off the anticoag so we can minimize chances of PE. Other patients, if it's not an urgent procedure, which most of the time, the GYN patients are very time sensitive, but say for a patient who needs prostate cancer treatment, they can safely wait three to six months, we may postpone their brachytherapy till they can safely come off anticoags. We also look for pulmonary conditions like severe COPD, pulmonary hypertension, severe OSA or recent pneumonia, substance abuse. Sometimes patients, we will get complex patients with high use of narcotics or benzodiazepines from their disease. Sometimes they have a history of abuse of these drugs. Sometimes they'll be on methamphetamine. We've seen all sorts of stuff over the years. And sometimes, especially if they're staying for an inpatient stay, their pain needs can be very complex. And so sometimes we have to have a plan ahead of time for how we're gonna care for these patients. I would just add some of our toughest patients to manage are actually patients with chronic pain because managing the acute on chronic pain after implant can be a major challenge for us. And we typically involve specialists from acute pain or palliative care to help us with those more challenging situations. I agree, I agree. Very high BMI as well. They metabolize these drugs differently. In anesthesia, it's trickier for ventilation when somebody has got a very high BMI. Their ventilation is often more shallow. So just all really important things to keep an eye on whenever we are getting these patients ready for brachytherapy. Also, of course, any organ failure, active seizures, et cetera. So it's always good to be in contact with anesthesia. If you have any concerns, you can always make a plan of care with them. So pre-procedure coordination. This is probably one of the most important slides and something that despite this being in the guidelines, still a lot of different areas, it's hard for them to meet these time constraints. But for GYN patients who will be undergoing external beam therapy prior to brachy, it's important, especially for cervical cancer patients that we get that brachytherapy scheduled and completed in a very narrow window afterwards. It's by 49 days. And that 49 days includes the four to five weeks of external beam. We wanna have all treatment done within that from the start of external beam to the end of brachytherapy. So we have to really have everything set to go. So we don't go beyond that window. And like Dr. Venkat said, it used to be 56 days, but recent data has come out that now actually 49 is the requirement. So nurses can really help with this, keep an eye on external beam completion. And if I have a patient on external beam who's really missing a lot of treatments where they're already going to be close to 49 days without even starting brachytherapy, I will alert our physicians and be like, do we want to start doing brachytherapy during external beam to try to like figure out how can we, we don't want to just let that date just keep going and going later and later and later. I'll involve them if I know I can't, it's starting to look like we can't meet that 49 day window. Another very important slide is this one. Patients often will get canceled due to chemotherapy naders hitting about the same time as their brachy. For vaginal cylinder patients, it's a little bit different because we're not puncturing any tissues and they're not getting anesthesia, but for tandem and ring tandem and Ovoid and brachyinterstitial, these patients that have been getting chemotherapy usually will hit their nader right around the time that we're starting our brachytherapy because they need to have a chemotherapy to sensitize the tumors to radiation, but then we hold it. But then about a week later is where we do that brachy and their counts are often dropping. So we do watch very carefully, their white count, their red count and platelets, especially about a week after. And then if the labs start to trend down close to brachytherapy, we can often intervene. And, you know, again, it depends what part of the world people are in, if they have access to these things, but here, if I have a patient who has very low blood count, we'll set them up for a transfusion. If they have a low white cell count, especially their absolute neutrophil count, we can get them set up with a colony stimulating factor medication prior to the brachytherapy to try to boost those counts up a little bit so we can proceed and not delay their procedure. And platelet counts affect a little how we're going to proceed with our anesthesia. Often we like to do spinal and epidurals for our patients to minimize postoperative pain. But if the platelets are too low, those procedures will not be considered safe. So knowing that ahead of time helps you counsel your patient on what to expect on the day of. Yeah. And best your chances for being able to do that spinal or epidural and not get canceled because their platelets are too low. We also have to give them bowel and diet prep. These are some different examples from different facilities. We do, most centers do practice this if they use a transrectal ultrasound to help guide the placement. Basically their bowels need to be clear. They need to be fasting not only for anesthesia, but to have their bowel empty. What we do is clear liquids starting the day before at noon, followed by, and at that time drink either magnesium citrate or do a saline enema. And then again in the evening and then nothing by mouth after midnight, but different centers practice different things, but it is something that the nurses will educate the patients on. So again, it's very important to learn what your institution's anesthesia preference is for hold of the different meds, anti-glycemic medication. If patients are fasting, of course we have to counsel them on what to do with their metformin or their insulin. Usually it involves a primary care provider as well. Anticoagulants again, we will clear that with whoever's prescribing them, make sure that they can safely come off of them. And then antihypertensives, we do usually encourage patients to take those the day of the procedure. Chemotherapy as well, we will usually hold that about a week prior to brachytherapy. And then again, your GIP, GLP-1 receptor agonists, those will interfere with anesthesia and they do not want these on board. What actually happens with these meds is they delay gastric emptying. It's part of why they work for making people feel full is they slow down your digestive system, but then you're more at risk of aspiration during anesthesia, which is why they don't want them on board. Do you know how long we're holding this? Yeah. If it's an oral pill, then you hold it for a day. And if it's an injection, it's usually given weekly. They want it held for at least a week. So vaginal cylinder brachytherapy on the day of the procedure, vaginal cylinder is the type that looks like this. It goes into the vagina. It does not puncture anything. And they walk in, they walk out. And usually these patients do not require sedation or anesthesia, usually here for about an hour. And they still need to have nurses available for education and emotional support. But in terms of rigorous nursing care, pain control and nausea and all those things, it doesn't really apply to this population very much. But we definitely need to be around to educate them and be there as a support. And also vaginal dilator teaching upon completion of treatment is just as important as with all the other types of brachytherapy. So day of procedure for the ones that are more intraoperative or interprocedural brachies, such as your tandem and ring, tandem and cylinder, tandem and ovoid, excuse me, or our interstitial implants. These are the ones that will involve anesthesia or sedation, pain control afterwards. So they're kind of their own group. So the flow for the day, when they're getting GYN interstitial HDR is we will prep the patient for the procedure. And if applicable, anesthesia or sedation often in a preoperative area or in a clinic, a lot of like we use a clinic room or a holding bay. And then the brachytherapy catheters or applicator will be inserted under anesthesia or sedation in either procedure room or in an OR theater. And then the imaging for the treatment will occur. So before Dr. Venkat or other physicians can make that plan with all the targeting, they have to have the applicator in place or the catheters, and then they have to have a CT or MRI or both to then do all of the targeting off of that. It's all customized to each patient. So that imaging will happen as they're waking up. We do have both the CT and an MRI in our department, and they will have that scan with the nurses there with the patients, keeping them comfortable. If they have claustrophobia with the MRI, we deal with that. And then that scan will go to the physicians and our physics team, and they will start the calculations, the planning. And the nurse at that point will just do bedside nursing and take care of them and keep recovering them from anesthesia. Then the treatment will be ready for delivery. They will connect them to the HDR afterloader or robot, which will show a photo of that. That's what actually treats the patient through those tubes or through the applicator. And at the end, the applicator interstitial needles will be removed. If they are staying overnight, because some patients do require multiple connections to the machine with the applicator in place, then they'll usually go to the inpatient ward. So in the pre-op area, our nurses actually do the pre-op, get them ready for the procedure in the preoperative bay. And this is usually nurses will just follow what mirrors the perioperative areas of their facility. For us, it's a standardized navigator that we use that has all of the questions that prompts us, you know, who's the physician? Is there consent? Do they have dentures? They need to take them out. Do they have contacts? They need to take them out. Any loose teeth, any jewelry. So we go through all of that. We put an IV in, we do some patient education, we'll send off labs, those types of things. For brachytherapy specifically for nursing is it's good for us to review with the patient and the family, what the day is going to look like as best we can. The flow for the day would kind of estimate a timelines. We have to remind the patient that afterwards they will need to be on flat bed rest when this device is in their pelvis because you can't sit up and bend it. And so they just need to be reminded of that as well as the family. And then review opportunities for support person, be able to visit the patient if windows of time exist. And for HDR brachytherapy, the type that we practice, there will be no radioactive precautions, no radiation precautions after treatment. And they can have visitors, it's fine. But for LDR brachytherapy where they actually use radioactive seeds, that is different. We practice just HDR here for our GYNs. So the importance of the labs, just to summarize again, kind of back to labs, but in the pre-op area, we send off fresh labs. So we are looking at those in pre-op. The CBC, again, the counts may drop before or after or during the course of brachy because they've had recent chemo. So we're looking for anemia, neutropenia, thrombocytopenia. Blood loss during the case can also contribute, especially when patients are coming back from multiple implants and tumors, especially larger ones that they can be very vascular and they can bleed a decent amount. So radiation helps with bleeding, but when we're putting the catheters in, sometimes we can cause bleeding or remove them. So we have to watch their counts for lots of reasons. And then the platelet count, again, the bleeding risk will increase if your platelets drop too low and it can have an impact on whether or not they can get an epidural or spinal, which we really like to give patients, especially those staying overnight just for better pain control. So nurses in particular can really play a significant role in monitoring for chemotherapy later, helping intervene prior to the day of procedure, which minimizes cancellations and improves outcomes because we can meet those treatment windows. So anesthesia types and role in GYN brachy. There's different levels of anesthesia and analgesia that we use. General is practiced by a lot of facilities where they put the patient completely under when lighter sedation is not adequate or when the procedure involves the airway. Some facilities just, they practice general for most of their brachytherapy and kind of opt away from spinals or epidurals or local anesthesia. Other teams kind of do what we do is we'll do a combination of local anesthesia or regional plus monitored anesthesia care or Mac anesthesia, which is not as deep as general, but it's still anesthesia. They're often still asleep, often use propofol or ketamine or different drugs like that, but they don't require intubation in there. They're still very comfortable. And then we do local as well. So we do a lot of that, but a lot of teams do default to general. And then conscious sedation is usually administered by a registered nurse, at least in the U S I do work with a lot of teams globally. And this varies depending on what country you're in and what your license is and what nurses are able to do there. But conscious sedation is usually a nurse giving it. It's usually a combination of a benzodiazepine and a narcotic, and it does require a high level of nursing judgment and training. This is something that I really like to be able to give to patients. And we're trying to get all of our nurses trained in this, especially for implant removals or just to keep people as comfortable as we can, but it requires training and making sure that we're doing so safely. And then epidural and spinal anesthesia is great. You can use these with or without systemic anesthesia. Usually we use it in conjunction and they can keep patients, you know, relatively numb, not completely numb, but relatively numb from about the waist down. And it really helps with pain control for these patients. And then local anesthesia numbing blocks, such as pudendal or paracervical block is something that our physicians do as well, which I think really makes a big difference. And I know you're shaking your head. We started doing this, I don't know, a couple of years ago, like on everybody. And I really feel like our patients are tolerating these implants pretty well with the addition of this local anesthesia. We use a combination of lidocaine and bupivacaine and we actually use mostly bupivacaine and that's because it will last for about three to four hours, which is typically our planning treatment and removal time. So we like having that on board. Yeah. So we, we do combined approach, which combined is usually better than any one thing by itself. So the role of the nurse in the actual intraoperative phase is general OR procedure. You know, each facility will have their standards of care for positioning, infection control, documentation. That's the same. We have to do the same thing. You know, we have to do the timeouts. We need to make sure the positioning is correct and make sure we're protecting the ulnar nerves and the brachial plexus and making sure there's not lumps and bumps underneath the patients and, you know, making sure that they are protected in the OR. There's a safety strap on that we're helping anesthesia during anesthesia induction. That's not unique to brachytherapy. That's just perioperative nursing. And then specifically for nursing, for brachy, we need to make sure we have brachytherapy catheters or needles in there, which can vary by what machine you have and manufacture, but they usually come in a few sizes. We want to have them available and unopened in the OR to minimize waste. And then we will open as the physicians determine what length they need, what size, and then we will get them opened up. We also need to be prepared for difficult urinary catheter insertion or hematuria and having dilators or coude catheters or two-way versus three-way urinary catheters in different sizes. It's just good to have a stash, even though you may rarely need them. When you need them, you need them. And then ensuring an anesthesiologist is aware to not set the patient up when you're done. It is routine and best practice is in the ORs for physicians, for anesthesiologists to move the patients over and set them up to 30 degrees. It's for airway protection and we have to break them of this habit and brachy, be like, don't sit them up, and educate our anesthesiologists, especially if they're not usually down there. And then the nurses may need to scrub in or circulate and not be scrubbed in during the case. This will vary by team. And in a lot of centers, radiation therapists actually are heavily involved with this as well. So interoperative positioning, we will usually use dorsal lithotomy, high and low. We need to make sure that their knees and their hips are supported and moved in unison when elevating or removing their legs from the stirrups to protect their hip joints. We need to avoid pressure in the groin or upper thigh when their legs are in stirrups and that safety strap sometimes can pinch them right on the top of their legs. Uh, especially if it kind of shimmies down a little bit to make sure they're not getting pinched there when they're asleep. And then we can put their arms on arm boards, or we can have them kind of lightly crossed on their chest, but not too much because you have to protect your brachial plexus on the patient. And then we will again, notify anesthesia when we're changing their position, because it can affect their blood pressure. This is an example of a setup for how Dr. Venkat does these crazy, awesome interstitial implants. The yellow thing is the, uh, template that goes up against the skin. And then when she knows what size of needle she wants, she'll put them through here. We put a cylinder through here and a tandem it's big green tandem and all sorts of stuff. But we do have a surgical tech who assists during the case and a lot of centers, again, it's a nurse or a radiation therapist. Some centers don't have anybody and the doctor has to kind of do it all. Um, but this is an example of a setup for a GYN interstitial implant. So epidural anesthesia plus or minus spinal for GYN brachy, there's a lot of benefits. I think in my opinion, way more benefits than maybe not. Um, but benefits are increased pain control for most patients that receive them. Uh, it can also decrease the amount of IV narcotics that are needed for multiple types of pain medications. It there's it's in the literature, um, that it really can improve their experience. And also they need less drugs and it can be useful in patients with respiratory comorbidities to help minimize anesthesia needed, especially if they've got COPD or, you know, um, I had a patient not too long ago with a paralyzed diaphragm, uh, you know, like different, different situations where you really want to minimize the things that affect the central nervous system, respiratory drive, you might be able to get good pain control with, uh, regional anesthesia things to consider is anesthesia or epidurals can be challenging in patients with very high BMI. They still can be done though. Um, we just need longer needles and, you know, to, to have a skilled anesthesiologist able to do it. Um, there's also a very small risk for last syndrome or local anesthetic systemic toxicity syndrome. It is rare, but it is often, you know, it's, it's very serious. I can kill people. Um, it's where the, um, anesthetic gets into the bloodstream and the treatment is, uh, life supportive measures, good, uh, advanced cardiac life support and, uh, intralipids. So we always make sure in our PIXIS or in our machine that dispenses medication, um, that we stock intralipids because we do so much of local and epidural anesthesia. And then it can be challenging for patients who have had previous lumbar spine surgeries or pathologies. And then most of the time patients are very, um, soothed by the idea of an epidural, but you do get some patients that it totally scares them. It gives them more anxiety than the procedure. It can trigger anxiety and they they're scared of the epidural. So, you know, trying to help them through and if they don't want it, we don't force it. You know, we, we give them that option, but you do have a small percentage of people that the epidural is something that scares them. Part of that is because they have to be awake for that portion, which some patients just, they're so terrified of the whole thing. They just want to be out as soon as possible. So that's a big, it'd be a big challenge. Yes. And so we're, you know, working through them with it. Um, also too, whenever we're putting the epidurals in and in the OR, the nurse is right there with the patient, they can get some a dad lamb during it from anesthesia. Very often they don't remember it, even though they are awake and sometimes just kind of getting them through it, holding their hands, being there with them, helping position them. Um, they, they do really well, but it does scare some, some patients. So nursing considerations with epidurals, um, again, not unique to brachy, but we do do a lot of epidurals. So this is something we really try to train our nurses. Well, in epidurals may lower your blood pressure and heart rate in some patients. And despite what many people think it can trigger nausea. I've had a lot of people say, oh, it's not going up to the brain. Like it's not going intravenously. Like it's not going to trigger nausea, but it can trigger nausea in some patients, especially when they're getting transported to and from, and they're getting some other pain meds. Like it can also cause them to be itchy. Um, so this is just something to watch for. I always ask patients, how's your stomach feeling? You know, you haven't any itching, itching is usually relieved with some Benadryl, um, or, or diphenhydramine, um, trying not to use the brand names. Cause I know they're called different things throughout the world. So diphenhydramine are a different anti-itch drug. And then, you know, nausea will treat separately. Dermatomes, it's important to know dermatomes may be asymmetrical. One side might be more numb than the other. Sometimes they're both numb, but it's not always the same. And then it's important to protect the patient's epidural line from getting pulled. This seems like common sense, but it's amazing how many times these epidurals can get tugged on with the transport, getting put on and off of a CT table, which these patients get a lot of CTs, and just making sure that line is protected and that it's not leaking. We had a couple of patients last year where their epidurals kept leaking right at the junction. And this is something that really like, they don't teach nurses a lot, but then we see it and we're not quite sure what to do. So when an epidural line is leaking, we will try to put it like an occlusive dressing on it. We let anesthesia know right away. So that way air is not getting in there and it's not an infection risk, and they will come in and troubleshoot it with us if it's more than just a simple loose connection. It's also important to label epidural lines clearly to ensure it's not mistaken for an IV line or that it's not hooked up to an IV line on accident. I have seen this happen. It happens all over the place each year. So it's really important to label epidural lines clearly and make sure that they are hooked up to the epidural and that IV lines are hooked up to the IVs and that they do not get mistakenly connected to the wrong thing. Patients will also not be able to report as accurately things that are too hot. Like if they have a heat pack on their low back, most of the time they don't get that hot, but if they have an epidural, we have to be careful. Or items like caps or bunched up blankets or syringes or different things that might get underneath them. So we have to really watch their skin and then bladder fullness, um, such as an occluded urinary catheter. I've seen this one time when I first started in brachytherapy and I had a patient who I was getting report for the morning and the nurse, I said, how was her, how was her urinary output? And they're like, Oh, it was hardly any. And I knew she had a hundred CCS an hour going in her IV. I knew that, uh, she didn't have any, you know, kidney disease. And I knew she had urinary stents cause we did have to put stents into her Foley. And I knew she had had a little bit of hematuria and I said, well, have you been irrigating? Have you been checking your, your, that your Foley's patent? They're like, Oh no, she was sleeping. And we, we didn't think too much of it. So of course, that's an issue. We did some education. I got the patient down and she had about a liter and a half in her bladder. Couldn't feel it at all. She had an epidural and it was completely occluded. And you know, luckily we were able to correct it, but it was really a good teaching point for the floor of make sure your eyes and nose makes sense. These patients can get hematuria, you know, and making sure that we, um, remember that they can't feel bladder fullness sometimes. So the teaching point for physicians to request, um, accurate, I know, moderate monitoring throughout your patient's hospital stay. I also put an irrigate Foley catheter order in. Sometimes I do it, you know, every four hours, depending on how concerned I am for hematuria. Typically, I just put it at every shift and I even specify how much saline I want to be irrigated. Um, and things like that. A lot of this starts with a doctor putting the orders in and communicating with our nursing team. Yeah. And then again, training the team outside your team that's taking care of them overnight. You know, they, they need to be kind of thinking outside the box of these patients are at risk for hematuria. They have needles right up by their bladder. They are healthy. This, I know don't make sense. They have an epidural. Why is their, their belly distended because her, her bladder was so full. So we, you know, it's just a good learning point. Remembering that brachytherapy is really weird. Um, it's true. People outside don't understand it and they almost, they like don't want to touch anything related to the implant. They're almost afraid of it. Um, so taking that fear away, educating, explaining what you're doing, why you're doing it is really helpful. Yep. That definitely. And then, um, having knowledge of last syndrome, we do do this as part of the annual competencies. I, you know, I try to train in our procedural area for annual competencies. I don't want to be assigning people things that they already know. Like how do you position somebody supine? How do you, I try to assign things that are high risk, low frequency things such as last syndrome or malignant hyperthermia, you know, and when I'm thinking of what could the nurses actually run into that they do need a refresher on last room is a really good example of that. So last syndrome again, is what is a serious complication that can occur if a drug is injected into a vessel instead of the tissues and can lead to cardiac collapse and death very quickly. You usually have cardiac signs and CNS signs such as metallic taste, perioral numbness, or tingling, which can progress to complete unresponsiveness, seizures, and coma, uh, cardiac sign that can go all the way up to a systole, uh, treatment is immediately stopping the injection, providing supportive measures, which get your crash cart and do, you know, for us, it's ACLS within the United States, um, but advanced cardiac life support, uh, however that looks in your, in your country. And then again, the treatment for this is intravenous lipid emulsion therapy, and it's good if you can have it on site, it's good to do. So preventing last syndrome, probably good for me to ask Dr. Venkat, how do you prevent last syndrome when you're giving local anesthesia? I think what I do when I am training medical students, residents, or even undergraduates is to really stress that local anesthetics can kill a patient if not given appropriately. Um, many things we do is start with calculating the total appropriate dose a patient can have even before we, we start. And that's all we draw up into our syringes. Um, so we won't over, um, over-medicate the patient. The most important thing we do is know where we're injecting. So we use ultrasound often to guide our needles. Um, so we can see, see the vessels, see, see our organs. Um, but the most important thing we do, and I can't say this too many times is you just withdraw your, you aspirate before injection. Anytime you move your needle in any direction, just keep aspirating. You can't aspirate too much. And I kind of drill this into my trainees heads because if this happens, it's, it's really serious, really fast. Um, and I'm not going to jinx it and say, I haven't seen this. Um, I'm just going to ask you, have you seen that? I have not. I had one patient who I know I'm, I'm like, literally it's making me nervous. I don't want to, I don't want it to happen tomorrow now, but, um, I have had one patient. I was very concerned. We had just done local and they started getting metallic taste around their lips. Um, but then it didn't progress anything and they, it didn't match the rest of the symptoms. Um, we still, you know, stopped and did supportive measures, but that was the closest thing where I thought it was going that direction, but it wasn't. So it's still really, I think the biggest thing is our physicians that do local practice really good techniques. So probably credit to you all as well for, for giving it safely. Um, but it's just important that staff knows about it, having true lipids on site and, uh, put people through training and, and remind the physicians as well. There's a really good link there. Um, you can Google it, um, but there there's lots of stuff online about it. So once the, uh, completion of catheter insertion, finishing the OR phase, if the interstitial needles are used again, it depends on what type of break you're doing. The RN or the MD will document the total number, including this, the size, length, et cetera. We'll put, if we put any fiducial markers or other items during procedure based on institutional guidelines, the anesthesiologist will eventually hand off the patient to the RN who will be doing the recovery. And then we will take the patient out of dorsal lithotomy, either before or after the HDR treatment for GYNs. Um, most of the time they take them out, but I've talked to teams who keep them in dorsal lithotomy the whole time and asleep the whole time until treatment's done. And then most teams I talk to as well as us, we will take their legs out of the stirrups for their scans and for their treatment, but we still keep them positioned with their legs on pillows. Then we monitor for hematuria, which can occur at any point during pelvic brachytherapy. So immediately postoperative nursing care, immediately after they're waking up. So the duration of recovery will depend on the type of anesthesia use, duration of the case and any patient variables that might make it harder for them to wake up or they wake up more quickly. Recovery criteria will vary by institution, but most facilities practice some version of like Q15 vitals and assessment for the nurses and continuous cardiac monitoring if it's available. And then RN will remain with the patient throughout. And then pelvic interstitial brachytherapy patients will usually have urinary catheters as well. Um, vaginal cylinder patients don't, I think tanamen ring, tanamen ovoid usually have, uh, I've looked at her. She's, she's more been more exposed to that than me because I know interstitial and cylinder the best. So interstitial definitely that we use, um, urinary catheter, same with tandem. Basic patient recovery tips. We will, this is, this is not unique to brachy, reorient patient periodically, make sure they're not going for their eyes. Patients waking up from anesthesia, love to scratch their face and their nose and their eyes. And they can give themselves a corneal abrasion pretty easily. Uh, the nurses need to let them rest in between time to set assessments for alertness. Um, fall precautions is a big one. Maintaining supplemental to, uh, maintain positioning and verifying their implant is protected pain control and monitoring for hematuria. So cardiac and respiratory monitoring, um, won't go through this too much. This is regular recovery stuff for nurses, but ventilation should be adequate before anesthesia hands, the patient over their blood pressure might be lower than in pre-op. Um, they may require supplemental O2. We need to make sure we have suction available and minimize the chance of aspiration, especially because they're flat and they're not allowed to be sat up. If they are going to throw up, we can't sit them up, but your best friend is reverse trend. Dellenberg position, which a lot of us think trend, but Dellenberg is this way. I turned Delberg is actually where your feet are higher than your head and reverses the opposite reverse trend. Dellenberg is great for nurses and for patients because, um, it is a way to get the patient's head up without jeopardizing your brachytherapy implant. So it was the position where patients hips and knees are not flexed, but the head and chest are 30 degrees above abdomen and legs, and it can maintain your implant integrity. Well, it helps you address what you're trying to do, which is nausea, vomiting, also turn their head to the side. If you can and have suction acid reflux or heartburn, this one is common, especially in our patients that stay overnight. They sometimes need to be slanted for awhile, uh, hypertension, uh, hygiene drinking, and it gives us an option for safety and them an option for comfort. Sometimes they just want to look around a little bit. And so by slanting them, uh, you can so pain control, multimodal pain control when recovering a brachytherapy patient is key and multimodal. It's exactly what it sounds like. We need to hit pain from different areas to treat it differently because not all pain is the same. So examples, adding acetaminophen, uh, or paracetamol, I think, as they call it outside of the U S to a narcotic medication or anti-inflammatory such as catorolac plus a narcotic. Um, we need to use caution with benzos and narcotics. You have to follow your policies because sometimes you cross the line into sedation and then combining meds purposely by using our nursing knowledge, consider onset duration and potential side effects to make the best choice. If I have a patient who's going to be here for many hours, I'm going to choose a longer acting narcotic over a quicker one, because I want them to be comfortable for a longer period of time. If we're wanting to give somebody an additional dose of pain medication for removal, we want to give something short acting, fast, fast acting. So we just have to use our nursing judgment for that. And then don't forget about the importance of music, deep breathing, relaxation, spirituality, friends, family, all the things that help pain control that are not drugs. So tips for GYN patients in particular, they get abdominal cramping and you treat it differently than surgical implant pain. I have played with this over the years, and I really believe that patients do well when you, when you treat them as separate types of pain. So abdominal cramping can occur in combination with surgical implant pain in the perineum, that abdominal cramping pain, women often describe it as similar to menstrual cramps. And it often responds to the things that women do for menstrual cramps, which would be, you know, um, uh, heat packs, uh, anti-inflammatory medication, um, you know, those things that help with the cramping and then the epidural or spinal anesthesia also helps, but, but warm packs can be very soothing, real low abdomen as well. Just to add about the cramping pain, it really comes from dilation of the cervix and placing a tandem through the uterus, um, through the cervix into the uterus. So if a patient doesn't have, have a uterus as a post hysterectomy patient, they're less likely to have that cramping. Um, I love anti-inflammatory medications for this pain. It is far better than narcotic pain medicine for this type of pain. However, often the patients with cervical cancers in place and have the uterus in place are the ones at risk for bleeding. So you really need to communicate with your physician who did the procedure to get a sense of that bleeding risk before. And another important thing too, is I'm, you know, I'm still learning as I'm looking at this slide, I said, women, um, we actually have had a lot of patients who identify as male who have a uterus needing gynecologic brachytherapy treatment. So, um, that's something important to remember as well, because they will still have menstruation sometimes or not. They still have the same organs and the pain and, um, that's, that's, uh, patients we're seeing more of that now too. And it's important to, uh, have to watch my wording in the slides. I'm still learning. Positioning patients with pelvic implants. Uh, if we keep them supine, we keep their legs up on pillows so that they're not pushing down, um, on the implant. So we keep their legs elevated. Uh, some facilities do allow their patients to be turned. It's really important if they're overnight patients that we turn them because they cannot stay in the same position, their whole inpatient stays, they're going to get skin breakdown. There is a way to turn these patients. Not every physician is okay with it. Um, and that's where I try to encourage not, not only nurses, but physicians, like you can safely do this with an interstitial implant. You can turn them in and that your implant will be fine. You just have to teach people in the patients how to do it. So there's step-by-step plant, their heels pillow lengthwise, they turn themselves knees and shoulders in unison. And then we keep the pillow between their legs. The implant will be free floating out the back and they can be on their side and get some relief from low back pain or just repositioning. And you can check their skin. Important thing is we don't want patients doing this on their own, but there is a way that you can safely do it. If you can get your physicians, uh, approval. Yes. And to get that approval, we're usually okay with it as long as we can image before treatment. So that's how we do it here. If patients stay overnight, we'll image in the morning with a CT scan. We'll fuse our planning scan with the current image and make sure nothing's moved. So we do actually feel very comfortable with Kayla's technique of turning patients. I am fully comfortable with that. Yeah. And trying to just get, I talk about this a lot at different conferences. And one of the things I get the most questions about afterwards is physicians asking if they really do okay with this repositioning. Like it's, it's surprising to a lot of people. You actually can reposition these patients. Uh, low back pain is common again, um, at elevating legs. Um, if the patient supine can help turning them to their side, if the physician allows, uh, warm packs, their low back and again, um, meds and then low back pain prevention can start in the OR, especially if they have a history of chronic low back pain, we can give them a little bit extra lumbar support. I am going to start to speed up a little bit. Um, we got a little bit more to cover here. Um, so pain control tips, managing patients with chronic pain or anxiety. It's important for nurses and physicians to determine if the patient is having pain, anxiety, or both. Um, sometimes anxiety can be assumed to be pain when it's actually anxiety. So we have to figure out, are they more anxious? Are they in pain or is it kind of a combination? So pain medication requirements, um, depending on what they're having, you know, they, they might need more intensive nursing, but we have to make sure that they're having anxiety, that we treat that as well. So hematuria management, hematuria can happen in pelvic brachytherapy. It's most common in our prostate population, but we see it in GYN as well. Uh, especially if the interstitial catheters are present or if there's bladder involvement that needs coverage, um, you may see this and the nurses have to be watching for the hematuria irrigating this out. So you don't have a big clot form in the bladder. You don't lose your Foley because it becomes occluded. And then if it doesn't clear after a lot of manual irrigation, you can switch patients to continuous bladder irrigation, which we see several times a year, but again, it's mostly in prostate patients, but we have had it in GYN as well. Uh, it's also important. One thing I've learned over the years is don't check the tubing here. If this is yellow, that doesn't mean that it's not bright red and occluded at the top of the tubing where it connects to the catheter. So always check up there as well. Impaired skin integrity, the role of the risk of skin integrity increases with longer stays as well as advanced age, low BMI, nutritional deficiencies is another one, um, or prolonged bedrest. We have to make sure we're turning patients, protecting their bony surfaces and, uh, just keeping that in mind to just, just basic, you know, nursing one-on-one there. Hypercoagulability is a real thing, especially in GYN patients. Some breaking patients do have increased risk of developing blood clots. Uh, it's a standard risk of surgical procedures, but also patients with advanced cancer have hypercoagulable tendencies, especially when coagulopathies are present. And then in brachytherapy, you have patients who have been on chemo. They have, um, some of them have advanced cancer. They, they need bedrest. So we really have to make sure we are staying ahead of, um, DVTs. And sometimes they come into us with DVTs already. So we have to watch for that when we're coordinating. So we need to use caution with patients with known active DVT. Um, we may speak to the MD or anesthesia as they may opt for the patient to not have an STD on that side. For nausea and emesis, nausea is not uncommon with brachypatients. It's a side effect of anesthesia, it's a side effect of narcotics, of transporting the patient to and from, and depending on what part of their body was treated can also be a residual side effect from external beam. So there's drugs you can use, 5-HT3 receptor antagonists such as Ondansetron work well. You can also use drugs like metoclopramide, but they increase GI motility and make patients have a bowel movement onto their implant. So it's not usually my first choice, but it is something you can also use stuff like compazine or different things like that. And then again, reverse Trendelenburg and having suction nearby. So HDR treatment, this is like two examples of the actual afterloader as it's called, or a robot or the brachytherapy machine that actually delivers the treatment to the patient through each catheter. And there's a couple of different vendors that make them. During the treatment, the patient will be connected with a bunch of hoses to this machine, and then the physicist and the physician will be present as well as often a radiation therapist, and it will deliver the prescribed treatment to the patient. Once they're all connected, they're in a vault, we're all out of the vault and monitoring the patient, and then the radiation takes place then. Some patients will have one treatment and others will have several and will need to be cared for in between. If an interstitial implant is in place, if the patient's all done with their treatment, they will have the interstitial implant or their tandem ring ovoid applicator removed upon completion. So implant removal, the nurses need to be ready to assist with controlling bleeding if necessary. Bleeding can have, it can be significant at times with gynecologic patients, especially if those interstitial needles are present. And so we never have the doctors doing this alone. We're always there helping them and have a setup. We have vaginal packing prepped and ready with long forceps so they can really pack up inside if needed. And then consider having a hemostatic matrix available as well. This is something we didn't do a long time ago. We've done this now for several years, but can you tell me more about why you like hemostatic matrices? So for when we do removals, our patients are awake. Hopefully they have a epidural on board, so they're still numb, but often you're removing implant and the hemorrhage can start right away and you don't have a lot of time to address the situation. You need to act immediately, you can pack, but that's very uncomfortable for patients. So if someone's bleeding a lot, I do like to insert some hemostatic matrix at the top of the cervix and then pack behind it to minimize the need to pack and repack. And it just seems to simplify things for us. I would also say that serious bleeding is pretty rare, but not uncommon, particularly in patients who've had chemo radiation therapy because their platelets will be low. Younger patients, I just see it all the time, the younger the patient, the more likely to have significant bleeding. Uterine fibroids are a big thing to watch out for. I would suggest using your transrectal ultrasound to avoid implanting your fibroids. That is extremely important. Large tumors. And then also when I'm in the OR, I keep track of who's bleeding with minimal instrumentation. And I assume those patients will likely bleed on removal as well. And if our team identifies somebody that, you know, we either just have a feeling they're going to bleed or the physician's concerned they're going to bleed, or they have enough of these risk factors, we'll make sure we have extra staff available just to be around in case they need additional assistance. So this is an example of what we have ready to take them out. We have a pad for any of the patient. We have eye protection for staff. My team tells me I sound like a broken record because I had blood go in my eye once, only once I was not wearing eye protection. And so my job now as our supervisor is to make everybody super tired of hearing me say, please protect your eyes because it's not fun. And you also have to then leave the removal because you have blood in your eye. And so eye protection, as well as just wearing something over your scrubs, like a gown or a surgical gown, just for, especially if you're irrigating, you can get a lot of splatters and stuff. So PPE for staff, pack of gauze, suture scissors, hemostat, packing supplies, again, bladder irrigation supplies, and then a hemostatic matrix if it's available. So fall prevention is important. I'm going to try to cover these next couple slides pretty quick. So we have a little bit of time for questions, but dizziness can occur in all ages, especially after flat bedrest is lifted. Our baroreceptors get a little bit lazy whenever we go from flat bedrest to standing and these patients can get orthostatic. So sitting them up slowly, despite their eagerness to get moving after being flat in bed for a while, we try to really get them up slowly over many minutes. Nurses should assess for orthostatic hypotension. And if it starts to show itself, catch it before it becomes an issue and we'll let the physician know and usually give them a bolus. And then once patient is ready, we will ask them to please get dressed, sitting down and not balancing on one leg to get their undergarments on. I cannot tell you how many patients I can catch them doing this. I'm like, please sit down. Cause that's a very avoidable fall risk. Basal-vagal reactions are also something we do see after brachytherapy, especially in the pelvic region. It's most commonly seen in our prostate patients, but we do see it in GYN as well, especially after implant removal or urinary catheter removal. And this can lead to significant falls and injuries if it's not recognized early. Signs of it coming on, once you are experienced in it as a nurse or as a physician, when you see it, you know exactly what it is. Patients all of a sudden become very pale or if they have darker skin, sometimes you'll see kind of a yellowness or a grayness or just pallor. And often their lips will turn a very, very different color. And there'll be a sudden onset of diaphoresis most of the time and patients just say, I don't feel good. And then if they're on the monitor, you'll notice that they'll get very bradycardic and their blood pressure usually will drop significantly. So preventing falls and increasing blood supply to their brain is the most important thing. This does correct itself. Our job as nurses and MDs is to keep them from hurting themselves while it corrects. So position does matter. If this is happening with them sitting up, don't let them keep sitting up. It's going to progress to syncope. So get them in a lower position such as laying down. And if they can't lay down, if you're not next to a bed, have them sit and put their head between their knees. And I just put my hand kind of right here on their shoulder. So in case they lose consciousness, they won't roll forward. And I keep them there. If they throw up, they lose consciousness. They're in a safe position. The blood flow to their brain is going to correct. And I'm able to have somebody get help while I make sure the patient's okay. Being in Trendelenburg with your head lower than your legs is the best position. If you're near a gurney and they will quickly wake up and re and recover. Maintaining IV access until the very end is something I highly encourage teams, even if they're up and walking around until they are physically leaving us, I think keep the IV lock in just so we have it. And then watch for emesis and have patient lay on their side if they're nauseated. It is self-limiting, irresponsible to fluids and time. Just knowing the sign early and preventing falls is our biggest job as nurses and as physicians. Again, leave the IV in to the very last moment. Discharge education after GYN brachytherapy, vaginal spotting is expected, but active vaginal bleeding of saturating more than a patent hour needs to be immediately addressed. We educate them that urinary burning or urgency may be present for the first few days to weeks, which can be minimized by hydration and reducing intake of acidic food or drink like coffee or spicy stuff or berries. And then using a medication to use to the urinary tract, such as finasal pyridine or other things can help as well. And then we educate them on signs of affection. This is basic nursing here, fever over one Oh one or 38.3 Celsius discharge that appears purulent, I'm not feeling good, increasing pain. All of those would be abnormal. And then we do prescribe antibiotics after interstitial brachytherapy. What about Tannum and ring or Tannum and Ovoid? It's been over five, six years. I don't know. I don't know either. They may after G I should know that, but we don't practice them here. So possibly after GYN Tannum and ring Tannum and Ovoid, but not after vaginal. So I would think it would not be required, but I wouldn't want to tell people. Okay. We're not sure on that one. We're all still learning. This is a very important slide. And one of our best slides to get close to ending on here, vaginal dilators after pelvic radiation. This applies to any patient with a vagina who has had treatment to any part of their pelvis. This includes our rectal cancer patients. Our GYN patients are not our prostate patients. I almost said prostate patients. That's not right. And it's important that they do it consistently and on a regular basis. So the vagina can change after radiation and it can get narrowed. It can start to stick to itself and get adhesions. And it can be very painful and very difficult to do pelvic exams, which we need to do as part of their followup. So we educate them to use these dilators. There's all different sizes. We tell them you do not need to go to the largest size, but kind of, you want to feel it stretching, but it shouldn't be painful. And we encourage them to use it in the shower. Sometimes that helps a little bit. Other patients, you know, they kind of find what works for them, but if they can do it in the shower as part of their regular routine, wash it afterwards, according to the instructions for use, most of the time, it's just, you know, washing with soap and water and laying it to dry. This helps keep the vagina open. It helps with future pelvic exams, and it maintains the functionality of the vagina as well. There is contradictory data out there, but we highly, highly recommend the use of dilators in the care of our patients. It can't hurt anything. It only helps. And we strongly believe it makes a big difference in the lives of these patients. So even though there's some data out there saying, ah, you might not need it. We strongly disagree with that. After vaginal cylinder, this are the ones that don't have interstitial needles. They didn't get anesthesia. We will still give them discharge instructions on when to return to clinic. We will usually have them do the vaginal dilators as well. They usually don't need antibiotics or pain meds, but they still may have some dysuria. We encourage hydration and it should improve with time. Last two slides are just really training your team with brachytherapy being a specialty. We have to make sure we're training people well for patients that have to leave rad on such as inpatient stay. We absolutely have to develop formalized scheduled training for units, uh, that have our patients. I am part of the annual and initial onboarding for the different inpatient units. I've held skills labs. I do do in services, but in services are a supplement. They should not be the primary way we teach people because you only catch maybe 25% of the staff that's working that night. You don't get the people on vacation, you don't get the night shift and errors occur. And so it has to be more formal training. So annual nursing competencies and initial onboarding nursing training. Um, I have wiggled my way in there to make sure brachytherapy is one of the things that's covered. There's a lot of resources for people wanting to learn more about being a nurse in brachytherapy, about brachytherapy in general. A huge thank you to IGCS today for hosting this webinar and being interested in this material. It's so critical for gynecologic cancer. Um, the American brachytherapy society is another society that we, we work heavily with, um, for just brachytherapy specific stuff. Um, we do have a nursing council through them and we're doing some, um, resources online there as well. Um, Canadian brachytherapy group, Jack Estro, which is out of Europe and a lot of, um, actually their span is out there centered in Europe, but it's basically brachytherapy outside the US. And then AORN is a good society for, um, perioperative nursing support. It's general, it's not brachy specific, but they helped, they help a lot of us know how to be OR nurses when we aren't OR nurses. So that was a good resource as well. There's our references for today. We cannot thank everybody for your time and interest in this webinar. Um, and we're ready for questions if there are any. Thank you so much, Kayla and Pooja. I don't know about anybody else, but I'm tired with all the work you must do. It's amazing. And I, you know, really showed really well how versatile the nursing role is in brachytherapy. Um, and yeah, you do it, you do some amazing stuff. So we do have one question in the chat, which is what is the threshold for hemoglobin and white blood cell count to start brachy? Well, I'll take that one. Yeah, I'll take that one. I think it's probably team and physician dependent, um, for, was it specifically about white cell count? Um, I actually don't care about the white cell count. I'm more looking at the absolute neutrophil count and my cutoff is 0.5. Um, I think, you know, if it's 0.49, you know, I'd probably push it over, you know, you have to weigh the importance of completing the brachytherapy on time versus the risk of proceeding. Um, you know, if it's on that borderline, you can maybe give some stronger antibiotics if you have those available. Um, but I think you need to feel comfortable as a, as a physician moving forward, but we've done 0.5 routinely without any complications. And if I see the accounts trending beforehand on patients, me and the PA that works on our service, we kind of tag teams. We have about 250 patients right now that we're tracking. Um, if I see their trends starting to go kind of one for the ANC or just under one, we'll usually proactively get them a colony stimulating factor just to try to boost those counts up prior. But yeah, if we see them kind of creeping down towards one on the ANC. For platelets, I was recently asked this, if I have a cutoff and I don't, um, have a cutoff for platelets I do for epidurals and spinals, well, that's anesthesia is cut off. Um, there's usually about a hundred, um, sometimes down to 75, depending on comfort level. But for me, um, I, I know I can handle the bleeding. So I pretty aggressive with the brachytherapy because we really don't want to post the really don't want to postpone that timeframe is so important for local control and overall survival. So I will push bleeding can be handled. Absolutely. Thank you. Um, I can't see any other questions in the chat. I was just going to ask in relation to, you know, patient education and support, obviously this is a very confronting treatment for, for our women. Um, and how do you, um, have that continued support for the patients when they are, you know, facing such a confronting treatment? I think it starts with our GYN oncologist, um, who can really set, set us up for success, um, with their counseling ahead of time. Um, by GYN oncologist, I think they tell the patients, um, I walk on water and that, you know, that sets up this just, um, comfort level from the beginning. And then at the consult, just being really honest about what it's like, um, all the different options for anesthesia, all the different experiences a patient can have, whether that's pain or, um, the bedrest, um, whatever your logistics are, and just taking that time to go through it multiple times. So I do it at consult, um, for as long as it takes. And then our physician's assistant actually will do it again, um, at a pretreatment visit, um, and go, just go through the steps one more time. And then in the morning of the procedure, um, we meet the patient again and, you know, I almost, we do the consent form and we do the consent form at that time actually. And we, we consent and we do that full process and go through it one more time. And then during the procedure and after while the nurse is one-to-one with the patient, I think a lot of what our nurses do is they're, they're physically there and they're talking to the patient, reminding like, these are the steps, this is what to expect. Um, these are things we can do to intervene. Um, and I, I think it's a continuous and constant conversation that goes on. And a lot of music today I've had reggae and the Eagles requested so, you know, to kind of all angles. And I think good patient coordination, the front end or patient navigation, I know both terms are used. Um, it it's something that if you do it well, which I strive to do, cause that's a big part of my role is it eases their anxiety. They feel like, cause often there's, there's hemonc, there's gynon, there's us, there's outside external being dog, like there's so many people where they're so anxious of what do I do? Where do I go? What, you know, and, and helping them be that kind of be that glue as best we can for them, um, is, is something I'm always trying to, to, I think it helps and it's something I'm always striving to really make my, my top priorities. So, so true. Thank you. Thank you both for that. That was an absolutely outstanding presentation and I'm giving, considering the time I'll hand over to Chrissy to, uh, finish this off for tonight. You're on mute. Yeah. Unfortunately, that is all the time we have for today, but thank you all for attending. Um, and I'd also like to thank our expert presenters, Kayla and Pooja and my co-chair, Anne. Uh, the recording of today's session will be available in the IGCS education 360 learning portal tomorrow. We also invite you all to complete the IGCS nursing certificate program. We and the IGCS nursing work group have developed a self-paced program that provides nurses with the necessary knowledge to provide evidence-based nursing care to patients with gynecologic cancers and empowers them to advocate for the best possible health outcomes. Also, if you are attending the IGCS 2024 annual global meeting in Dublin, we invite you to join us on October 15th for the first ever IGCS nursing symposium. More information may be found at IGCSmeeting.com. We wish you all, uh, uh, we wish you all well and continued health and safety. Stay well. Thank you. Thank you all for joining.

nursing care

gynaecologic brachytherapy

Anne Mellon

Chrissy Donovan

Kayla Kafka-Peterson

Dr. Pooja Venkat

oncology

HDR brachytherapy

LDR brachytherapy

patient education

pain management

care coordination

gynecologic cancers