Reducing patient reactions during fluorescein angiography:

An unstudied theorem

Side effects and reactions of sodium fluorescein can be unpleasant and potentially harmful to the patient, but with a few tricks of the trade, you may be able to reduce the incidence in your office.

Proper atmosphere is of the utmost importance. What is going through your patient’s mind may be the single factor for a lot of common side effects of sodium fluorescein. By providing an environment of calm and assurance, the patient will feel more at ease, possibly lowering an already heightened sense of anxiety. Once a patient hears that they have a sight threatening condition, they tend to stop processing the information that follows. Regardless of how much time you spend explaining the fluorescein angiogram, they will inevitably have questions for the photographer.

Your photographer needs to be well versed in the fluorescein angiography protocol for your office. After hearing the doctor explain it a few times, they can take on the responsibility of repeating the common side effects, need for the test, and the process itself. The photographer may want to go over the consent form again after the doctor and patient have reviewed and signed it. An informed consent allows for discussion of all possible risks, but downplaying the risks may help calm a patient.

Practice, practice. A well rehearsed photographic routine will portray professionalism and instill confidence in patients. Have a written protocol for patient care, step by step, when photography is ordered. Communication between the doctor and photographer is crucial. Once an angiogram is deemed necessary, the patient should be escorted directly to the photography room, where a knowledgeable photographer (she must be knowledgeable, she said the same thing the doctor did) explains the procedure and answers any questions the patient has. The photographer is carrying on a conversation with the patient, taking an interest in the dialogue, all the while drawing the fluorescein up, setting the camera, and taking pre injection green photographs.

A patient is typically in a very vulnerable position at this point. They have lost their sense of control, and are probably frightened. By establishing a relationship, a sense of bonding, the photographer is in a good position to give some of that control back to the patient. Making the patient feel a part of the team by asking them their IV history, which arm do they prefer, where do nurses commonly draw blood from, etc., will allow the patient to participate and give them a sense of control in this situation. The patient will feel relaxed and more trusting of the staff. Along with trust, a patient must sense compassion from the photography staff. A hand on the shoulder or arm creates a physical connection that lets the patient know you are listening to them. At that moment, the patient is the focus of your attention, and no matter how bad your day is going, chances are the patient is having a worse one.

During the injection, talk to the patient, as silence can be more awkward when you are searching for a vein. Again, communicate with the photographer when the injection is started and finished. The photographer should talk to the patient during the angiogram, asking how the patient is doing and reassuring the patient. The patient needs to know that they are doing what you ask, and praising the patient will prevent the patient from talking during the angiogram. If a patient does feel nauseous during the angiogram, allow the patient to sit back and relax. This side effect typically occurs well after the initial transit phase, so allowing the patient a minute to recover will not ruin the angiogram, and the patient needs to be made aware of this.

Observation and discussion with colleagues has time and again brought up the issue of temperature in the photography room. It appears that a room kept between 64 and 68 degrees lessens the incidence of nausea and vomiting, while a warmer room, above 70 degrees, seems to increase the incidence. This has always been an unstudied, lengthy discussion among photographers, as is the rate of injection.

To provide a quality angiogram, with proper contrast, the dye should be injected in a bolus, typically 1 cc per second. A bolus injection has never been defined as a factor in patient side effects, and there is no evidence otherwise. By slowly injecting sodium fluorescein, the camera may capture slight fluorescence in the retinal vessels while the dye is still being injected. There will not be enough dye concentration to properly record the transit phase of the angiogram or the arm to eye time, both potentially important factors in the study. Obviously vessel condition plays a factor in this scenario, and if an infiltration is feared, smaller needles or a refined technique may be called
 for.

Author:

Darrin Landry is the owner of Bryson Taylor Inc., an ophthalmic consulting company
specializing in ophthalmic photography and technical skills instruction.