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Neodymium (Nd) is one of the most famous members of rare earth elements family. With the increasing global demand for Nd, it can inevitably enter the environment and affect the ecological environment through the food chain and other ways. Therefore, it is very important to study the biological effects of Nd. In this study, the biological effects of 3 kinds of Nd compounds, i.e. neodymium oxide (Nd2O3), neodymium chloride (NdCl3) and neodymium nitrate (Nd(NO3)3), were evaluated by using silkworm models through the method of intravascular injection. Each of the three Nd compounds was prepared into 6 groups at different concentrations (40, 50, 60, 70, 80, 90 μg/μL). The results show that within the certain concentration range, Nd compounds show great damage to the growth of silkworms since high death rate is observed: the death rate from Nd2O3 group is floating between 30% and 80%, the one from NdCl3 group is between 17% and 33% and that from Nd(NO3)3 group is between 23% and 37%. It also reveals that Nd compounds have some negative effects on the body length and weight of silkworms. However, the histophysiological study shows that the three Nd compounds cause no obvious negative effects on the cell morphologies in midgut, fat body and silk gland. The XRD and FTIR spectra show that the secondary and the crystalline structures of silks are not destroyed, the TGA and DTG data exhibit that the thermal stability of silks is not damaged, and the tensile test shows that the mechanical properties of silks are not affected significantly by the intake of Nd compounds. In general, the intake of Nd compounds has significant inhibitory effects on silkworm growth but little negative impact on silk structures or cell morphology, the study can provide useful toxicological data for the safe application of Nd compounds in various fields.

Background Aspiration testing before filler injection is controversial. Some believe that aspiration can help prevent inadvertent intravascular injection, whereas others cite false-negative results and question its value given that the needle position always changes somewhat during injection procedures. Objectives The authors sought to test the relation of false-negative results to the viscosity of the material within the needle lumen and determine whether a less viscous material within the needle lumen could decrease the incidence of false-negative results. Methods In vitro aspiration tests were performed utilizing 30-G and 27-G needle gauges, 2 cross-linked hyaluronic acid fillers, normal saline bags pressurized at 140 and 10 mmHg to mimic human arterial and venous pressures, and 3 needle lumen conditions (normal saline, air, and filler). Testing was repeated 3 times under each study condition (72 tests in total). For in vivo correlation, aspiration tests were performed on femoral arteries and central auricular veins in 3 rabbits (4–5 aspirations per site, 48 tests in total). Results In vitro and in vivo testing utilizing 30-G needles containing filler both showed false-negative results on aspiration testing. In vitro and in vivo testing utilizing needles containing saline or air showed positive findings. Conclusions False-negative results from aspiration testing may be reduced by pre-filling the needle lumen with saline rather than a filler. The pressurized system may help overcome challenges of animal models with intravascular pressures significantly different from those of humans. The adaptability of this system to mimic various vessel pressures may facilitate physiologically relevant studies of vascular complications.

When considering dermal filler injections, the brow and low forehead have been considered an area of high reward but also high risk for intravascular injection and therefore a relative “no-fly zone” especially for the inexperienced. The supraorbital (SOA) and supratrochlear artery (STA) as well as the less consistent superficial paracentral and central arteries are implicated in intravascular injection. Details relating to the transition of the SOA and STA from the orbit to subcutaneous fat and the precise location with respect to discrete ligamentous structures and fascial planes have not been well described and are confusing, in part due to the complexity of the fascial planes in this zone. The authors of this study have set out to clarify the 2- and 3-dimensional (3D) relation of the SOA and STA to these anatomic planes as they pass from deep to superficial.1 Key to understanding their findings and visualizing a potential clinical application is a thorough comprehension of the anatomy.

Background Owing to the increase in the number of medical procedures performed every year, the frequency of filler injection-related complications has also increased. Although slow, gentle injections with low pressure are usually considered to be safe, the differences in ejection pressure during a filler injection remain to be determined. This study aimed to identify the optimal pressure during filler injections and evaluate its capacity to overcome the arterial blood pressure and reflux the filler material. Methods Twelve combinations of four hyaluronic acid (HA) fillers with different rheological properties and three needles of different diameters were assessed to determine the force exerted by the injection model. The ejection forces corresponding to varying injection forces were measured and HA filler ejection pressures were calculated. Results The highest and lowest injection forces were achieved using 30- and 25-G needles, respectively. In accordance with the expected ejection force, high ejection pressure was achieved by administering the HA filler under a high injection force. Irrespective of the injection force, the ejection pressure was likely to be higher than the vascular pressure at the time of entry into the vessel, rendering the injection dangerous. Conclusion During filler injection, penetration of blood vessels and intravascular injection can be avoided by approaching the target area gently using a cannula or needle.

Background Aesthetic physicians rely on certain anecdotal beliefs regarding the safe practice of filler injections. These include a presumed safety advantage of bolus injection after a negative aspiration. Objectives The authors sought to review and summarize the published literature on inadvertent intravascular injection of hyaluronic acid and to investigate whether the technique of aspiration confers any safety to the practitioner and the patient. Methods Pertinent literature was analyzed and the current understanding of the safety of negative and positive aspiration outlined. Results The available studies demonstrate that aspiration cannot be relied on and should not be employed as a safety measure. It is safer to adopt injection techniques that avoid injecting an intravascular volume with embolic potential than utilize an unreliable test to permit a risky injection. Conclusions To prevent intravascular injection, understanding “injection anatomy” and injection plane and techniques such as slow, low-pressure injection are important safety measures. Assurance of safety when delivering a bolus after negative aspiration does not appear to be borne out by the available literature. If there is any doubt about the sensitivity or reliability of a negative aspiration, there is no role for its utilization. Achieving a positive aspiration would just defer the risk to the next injection location where a negative aspiration would then be relied on. Level of Evidence: 4

Background: Local anesthetic systemic toxicity (LAST) has been reported as a serious complication of local anesthetic (LA) peripheral injection. The signs and symptoms of LAST are highly variable, and the challenge remains to confirm its diagnosis. In this context, the determination of LA plasma concentration appears as a valuable tool to confirm LAST diagnosis. The aims of this study were to describe observed LA concentrations in patients suspected with LAST and their contribution to diagnostic confirmation. Methods: We retrospectively reported suspected LAST in patients for which at least one plasma LA concentration was determined to confirm diagnosis of LAST. Data collection came from our pharmacological laboratory’s database. Clinical signs and symptoms of toxicity, their onset time and observed LA concentrations were used to confirm LAST diagnosis. Results: 33 patients who presented with suspected LAST after ropivacaine and/or lidocaine administration were included. Prodromal symptoms were observed in 13 patients. Isolated central nervous system (CNS) toxicity occurred in 11 patients, and combined CNS and cardiovascular toxicity occurred in 12. One, two or three venous plasma samples were performed in 11, 3 and 19 patients, respectively. Toxic plasma LA concentrations were observed in three patients, receiving peripheral LA injection using lidocaine (16.1 µg/mL) and ropivacaine (4.2 and 4.8 µg/mL). Conclusion: This study presents an important biological and clinical dataset of patients who presented with suspected LAST. Plasma LA concentrations could bring valuable information in the diagnosis of LAST but requires rigorous sample protocols.

International audience; Background and objectives: Injection pressure monitoring can help detecting the needle tip position and avoid intraneural injection. However, it shall be measured at the needle tip in order to be accurate and reproducible with any injection system and non operator-dependent. With an innovative system monitoring the injection pressure right at the needle tip we show that it is possible to early detect an intraneural and also an intravascular injection.Methods: We performed supraclavicular block-like procedures under real-time ultrasound guidance on two fresh cadaver torsos using a sensing needle with an optical fiber pressure sensor within the shaft continuously measuring injection pressure at the needle tip. A total of 45 ultrasound-guided injections were performed (15 perineural, 15 intraneural and 15 intravenous injections).Results: Mean (SD) injection pressure after only 1 mL injected volume was already significantly higher for the intraneural compared to the perineural injections: 70.46 kPa (11.72) vs 8.34 (4.68) kPa; P < .001. Mean (SD) injection pressure at 1 mL injected volume was significantly lower for the intravascular compared to the perineural injections: 1.51 (0.48) vs 8.34 (4.68) kPa; P < .001.Conclusions: Our results show that injection pressure monitoring at the needle tip has the potential to help identifying an accidental intraneural or intravascular injection at a very early stage.

Purpose As filler procedures have increased in popularity, serious injection-related complications (e.g., blindness and stroke) have also increased in number. Proper and effective training is important for filler procedure safety; however, limitations exist in traditional training methods (i.e. anatomical illustrations and cadaver studies). We aimed to describe the development process and evaluate the usability of a virtual reality (VR)-based aesthetic filler injection training system. Materials and Methods We developed the virtual reality hardware for the training system and a short guide, with a lecture regarding safe filler injection techniques. One hundred clinicians who attended a conference tested the training system. Participants completed system usability scale (SUS) and satisfaction questionnaires. Results Nearly half of the participants were aged 35–50 years, and 38% had more than 5 years of aesthetic experience. The mean SUS score was 59.8 (standard deviation, 12.23), with no significant differences among the evaluated subgroups. Approximately 76% of participants provided SUS scores of more than 51, indicating acceptable usability. Participants aged 35–50 years were more likely to rate the system as having poor usability than were those aged Conclusions This study was the first to develop and explore the usability of a VR-based filler training system. Nearly three-fourths of participants indicated that the training system has an acceptable level of usability. However, assessments in precise target audiences and more detailed usability information are necessary to further refine the training system. Level of evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Contrast-induced acute kidney injury (CI-AKI) is a common complication after intravascular injection of iodinated contrast media, and it is associated with a prolonged in-hospital stay and unfavorable outcome. CI-AKI occurs in 5% to 20% among hospitalized patients. Its diagnosis relies on the increase in serum creatinine levels, which is a late biomarker of kidney injury. Novel and early serum and urinary biomarkers have been identified to detect kidney damage before the expected serum creatinine increase.

Background Pre-injection aspiration procedures could increase safety during soft tissue filler injections. However, various influencing factors have been detected in vitro that could result in false negative aspiration results. Objective A case series was retrospectively investigated to identify factors contributing to positive blood aspiration procedures in vivo. Methods This study evaluated 213 clinical cases positive for blood aspiration documented in an Asian population: 208 females (43.8 ± 7.2 years old) and 5 males (46.8 ± 7.8 years old) during soft tissue filler injections. Injection location, layer (depth) of injection, product injected, size of utilized needle (gauge), length of needle (inch), priming of needle (yes/no), injection angle (degree), and time until blood was visible in the needle hub (seconds) were evaluated. Results The most frequent location where a positive aspiration was observed was the pyriform fossa (n = 56; 26.3%), the most frequent plane was the supra-periosteal plane (n = 195; 91.5%), and the most frequent needle utilized was a 27G needle (n = 125; 58.7%). Statistically significantly more positive cases were identified when the needle was primed compared with an unprimed needle (P Conclusions Pre-injection aspiration could be a valuable tool to prevent accidental intravascular injection of soft tissue filler. The results of the present investigation show that aspiration can be performed with an acceptable aspiration time, that is, less than 2 seconds, if a suitable product/needle combination is chosen. Level of Evidence: 4

Background Inadvertent intra‐arterial injection of dermal fillers including calcium hydroxylapatite (CaHA) can result in serious adverse events including soft tissue necrosis, permanent scarring, visual impairment, and blindness. When intra‐arterial injection occurs, immediate action is required for optimal outcomes, but the infrequency of this event means that many physicians may never have experienced this scenario. The aim of this document is to provide evidence‐based and expert opinion recommendations for the recognition and management of vascular compromise following inadvertent injection of CaHA. Methods An international group of experts with experience in injection of CaHA and management of vascular complications was convened to develop a consensus on the optimal management of vascular compromise following intra‐arterial CaHA injection. The consensus members were asked to provide preventative advice for the avoidance of intravascular injection and to produce a treatment protocol for acute and delayed presentation. To ensure all relevant treatment options were included, the recommendations were supplemented with a PubMed search of the literature. Results For prevention of intra‐arterial CaHA injection, consensus members outlined the importance of a thorough knowledge of facial vascular anatomy and patient history, as well as highlighting potential risk zones and optimal injection techniques. Individual sections document how to recognize the symptoms of vascular occlusion leading to vision loss and tissue necrosis as well as detailed treatment protocols for the management of these events. For impending tissue necrosis, recommendations are provided for early and delayed presentations with treatment protocols for acute and follow‐up treatment. A separate section details the treatment options for open and closed wounds. Conclusions All physicians should be prepared for the eventuality of intra‐arterial injection of a dermal filler, despite its rarity. These consensus recommendations combine advice from aesthetic experts with the latest reports from the published literature to provide an up‐to‐date office‐based protocol for the prevention and treatment of complications arising from intra‐arterial CaHA injection.

Purpose A relayed nuclear Overhauser enhancement (rNOE) saturation transfer effect at around -1.6 ppm from water, termed NOE(-1.6), was previously reported in rat and human brain, and some publications suggest that it may be related to blood. Here, we studied whether the NOE(-1.6) arises from blood through in vivo and ex vivo experiments. Methods To evaluate the contribution from in vivo blood to NOE(-1.6), intravascular signals in rat brain were suppressed by two approaches: (1) signal acquisition with a diffusion-weighting of b = 400 s/mm2 ; (2) intravascular injection of 5 mg/kg monocrystalline iron oxide nanoparticle (MION). Ex vivo blood sample was also prepared. The signals were acquired using a chemical exchange saturation transfer (CEST) pulse sequence. Multiple-pool Lorentzian fitting of CEST Z-spectra was performed to quantify the NOE(-1.6) signal. Results There are no significant variations in the fitted in vivo NOE(-1.6) signals when measured with or without diffusion-weighting, but significant signal decease does occur after injection of MION. The NOE(-1.6) signal from ex vivo blood is weaker than that from in vivo tissues. Conclusion Considering the relatively small volume of blood in brain, the in vivo experiments with diffusion weighting and the ex vivo experiments both suggest that the NOE(-1.6) is not mainly from blood. The mechanism for the in vivo experiments with MION are less clear. MION not only suppresses MR signals from intravascular space, but changes the susceptibility in the perivascular space. This result suggests that although the NOE(-1.6) is not mainly from blood, it may be vasculature dependent.

Lymphoscintigraphy represents the "gold standard" for diagnosis of lymphedema, but an important limitation is the lack of procedural standardization. The aim of this Italian expert panel was to provide a procedural standard for lymphoscintigraphy in the evaluation of lymphatic system disorders. Topic anaesthetic gels containing lidocaine should be avoided. Patients should remove compressive dressings. Total recommended activity for 99mTc-nanocolloid administration in adults is 74MBq, or 37MBq per limb and per investigated compartment, in single or multiple aliquots. 2-3 subcutaneous injections should be performed (II-III±I interdigital space of each hand/foot), avoiding intravascular injection. Deep lymphatic system of lower limbs should be evaluated in presence of dermal back-flow or lymphatic stasis (1-2 subfascial administrations in retro-malleolar or plantar region). Planar images should be acquired from injection site to liver with whole-body or serial static acquisitions 20' and 90' after subcutaneous administration. Additional information on lymphatic pathways is obtained after a quick and/or prolonged exercise protocol. SPECT/CT is recommended to study the thoracic, abdominal and pelvic territories. When required, deep lymphatic system of lower limbs should be evaluated with static acquisition 90' after subfascial administration. The report should describe administration and imaging procedure, exercise protocol, qualitative and semi-quantitative analysis (wash-out rate, transport index), potential sources of error. Due to the essential role fulfilled by lymphoscintigraphy in clinical management of primary and secondary lymphedema, an effort for the standardization of this technique should be made to provide the clinicians with a homogeneous and reliable technical methodology.

Purpose: 19F-MRI is gaining widespread interest for cell tracking and quantification of immune and inflammatory cells in vivo. Different fluorinated compounds can be discriminated based on their characteristic MR spectra, allowing in vivo imaging of multiple 19F compounds simultaneously, so-called multicolor 19F-MRI. We introduce a method for multicolor 19F-MRI using an iterative sparse deconvolution method to separate different 19F compounds and remove chemical shift artifacts arising from multiple resonances. Methods: The method employs cycling of the readout gradient direction to alternate the spatial orientation of the off-resonance chemical shift artifacts, which are subsequently removed by iterative sparse deconvolution. Noise robustness and separation was investigated by numerical simulations. Mixtures of fluorinated oils (PFCE and PFOB) were measured on a 7T MR scanner to identify the relation between 19F signal intensity and compound concentration. The method was validated in a mouse model after intramuscular injection of fluorine probes, as well as after intravascular injection. Results: Numerical simulations show efficient separation of 19F compounds, even at low signal-to-noise ratio. Reliable chemical shift artifact removal and separation of PFCE and PFOB signals was achieved in phantoms and in vivo. Signal intensities correlated excellently to the relative 19F compound concentrations (r−2 = 0.966/0.990 for PFOB/PFCE). Conclusions: The method requires minimal sequence adaptation and is therefore easily implemented on different MRI systems. Simulations, phantom experiments, and in-vivo measurements in mice showed effective separation and removal of chemical shift artifacts below noise level. We foresee applicability for simultaneous in-vivo imaging of 19F-containing fluorine probes or for detection of 19F-labeled cell populations.

Alopecia secondary to facial filler injections is a highly unusual sequela. Only 2 cases of hyaluronic acid-induced alopecia have been reported to date. Accumulating evidence suggests vascular compromise as its etiology, which can be accidental intravascular injection or external compression by overfilled materials. We hereby present, to the best of our knowledge, the first case of localized nonscarring and scarring alopecia secondary to autologous fat grafting and review the literature regarding filler-induced alopecia.

Background: Cervical transforaminal epidural block (CTEB) is a useful option in the diagnosis and treatment of cervical radicular pain. However, inadvertent intravascular injection can lead to severe neurologic complications. Blunt needles are considered to displace instead of penetrate vessels because of their dull needle tip. Objectives: To investigate whether there is a difference between blunt and sharp needles in intravascular injection rates during CTEB. Study Design: Prospective, randomized, clinical trial. Setting: A tertiary hospital in South Korea. Methods: After institutional review board approval, 108 patients undergoing CTEB for treatment of radicular pain resulting from spinal stenosis and herniated nucleus pulposus were randomly assigned to one of 2 needle groups (blunt needle or sharp needle). The needle position was confirmed using biplanar fluoroscopy, and 2 mL of nonionic contrast medium was injected to detect intravascular injection. Intravascular injection was defined as the contrast medium spreading out through the vascular channel during injection under realtime fluoroscopy. This study was registered in ClinicalTrials.gov. Results: The intravascular injection rate was not significantly different between the blunt needle and sharp needle groups (35.2% vs. 33.3%, P > 0.05). The procedure time was longer in the blunt needle group than in the sharp needle group (101.00 ± 12.4 seconds vs. 56.67 ± 8.3 seconds, P < 0.001). Limitations: This was a single-center study. Additionally, the physicians could not be blinded to the type of needle used. Conclusions: In the present study, use of a blunt needle did not reduce the rate of intravascular injection during CTEB compared to use of a sharp needle. In addition, procedure time significantly increased with blunt needle use compared to sharp needle use. Key words: Analgesia, bleeding, blunt needle, cervical spine, clinical trials, complications, intravascular injection, radiculopathy, sharp needle, transforaminal epidural block

Background: Transforaminal epidural block (TFEB) is an effective treatment option for radicular pain. To reduce complications from intravascular injection during TFEB, use of imaging modalities such as real-time fluoroscopy (RTF) or digital subtraction angiography (DSA) has been recom mended. In this study, we investigated whether DSA improved the detection of intravascular in jection during TFEB at the whole spine level compared to RTF. Methods: We prospectively examined 316 patients who underwent TFEB. After confirmation of final needle position using biplanar fluoroscopy, 2 mL of nonionic contrast medium was injected at a rate of 0.5 mL/s under RTF; 30 s later, 2 mL of nonionic contrast medium was injected at a rate of 0.5 mL/s under DSA. Results: Thirty-six intravascular injections were detected for an overall rate of 11.4% using RTF, with 45 detected for a rate of 14.2% using DSA. The detection rate using DSA was statistically dif ferent from that using RTF (p=0.004). DSA detected a significantly higher proportion of intravas cular injections at the cervical level than at the thoracic (p=0.009) and lumbar (p=0.011) levels. Conclusion: During TFEB at the whole spine level, DSA was better than RTF for the detection of intravascular injection. Special attention is advised for cervical TFEB, because of a significantly higher intravascular injection rate at this level than at other levels.

The Contrast Media Safety Committee (CMSC) of the European Society of Urogenital Radiology (European Society of Urogenital Radiology (ESUR)) updated its 2011 guidelines for the prevention of post-contrast acute kidney injury (PC-AKI). The recommendations are based on literature review data. The updated guidelines will be presented in two parts: Part 1 are discussed clarification of terminology (in particular differences between PC-AKI and contrast-induced nephropathy), the best ways to estimate glomerular filtration rate (eGFR). There were refined risk factors of PC-AKI, including by intravenous and intra-arterial routes of administration of the contrast agent. The key points of the updated recommendations are: 1. PC-AKI is the preferred term to characterize the impairment of renal function after the administration of a contrast agent; 2. PC-AKI has many causes for development; 3.Risk of development of AKI with intravascular injection of a contrast agent, overestimated; 4. Important risk factors for PC-AKI are chronic kidney disease and dehydration.

International audience; Utility of macrophages in an antitumor strategy based on the vectorization of iron oxide nanoparticles This Trojan horse strategy aims at specifi cally killing tumor cells. To achieve this goal, High-Z-element nanoparticles brought by macrophages are stimulated using low doses of X-ray radiation. The nanoparticles (namely FERINJECT®) liberate toxic photoelectrons in situ without damaging the surrounding healthy tissues. With its specifi c targeting of cancer cells, this promising anticancer strategy could greatly improve the effi ciency of current radiotherapy. Many solid tumors and their metastases are still resistant to current cancer treatments such as chemo-and radiotherapy. The presence of a small population of Cancer Stem Cells in tumors is held responsible for relapses. Moreover, the various physical barriers of the organism (e.g. blood-brain barrier) prevent many drugs from reaching the target cells. In order to alleviate this constraint, we suggest a Trojan horse strategy consisting of intravascular injection of macrophages loaded with therapeutic nanoparticles (an iron nanoparticle-based solution marketed under the name of FERINJECT®) to bring a high quantity of the latter to the tumor. The aim of this article is to assess the response of primary macrophages to FERINJECT® via functional assays in order to ensure that the macrophages loaded with these nano-particles are still relevant for our strategy. Following this first step, we demonstrate that the loaded macro-phages injected into the bloodstream are able to migrate to the tumor site using small-animal imaging. Finally, using synchrotron radiation, we validate an improvement of the radiotherapeutic effect when FERINJECT®-laden macrophages are deposited at the vicinity of cancer cells and irradiated.

Ophthalmological complications are infrequent problems due to dental local anaesthesia, diplopia being the most common among them. The intravascular injection of anaesthetic,since the cause of the problem and therefore it should be avoided inorder to prevent accidents at ocular level.1Ophthalmologic complicationstake place as a result of maxillary andor mandibular injections.2,3 The most commonly encountered complications affecting the eyes including blurring of vision, diplopia, mydriasis, palpebral ptosis andamaurosis(temporary or permanent).4,5 The dentist should be aware of these complications to avoid being perplexed by this unexpected circumstance, thus adversely affecting the doctor- patient trust.6Herewith we discuss the association between the ocular side effects and dental local anesthesia.

Conventional anticancer therapies exploiting platinum-based drugs rely principally on the intravascular injection of the therapeutic agent. The anticancer drug is distributed throughout the body by the systemic blood circulation undergoing cellular uptake, rapid clearance and excretion. Consequently, only a small portion of the platinum-based drug reaches the tumor site, which is associated with severe side effects. For this reason, targeted delivery systems are of great need since they offer enhanced and selective delivery of a drug to cancerous cells making the therapy safe and more effective. Up to date, a variety of the Pt-based drug targeted delivery systems (Pt-based DTDSs) utilizing nanomaterials have been developed and tested using a range of analytical techniques that provided essential information on their synthesis, stability, biodistribution and cytotoxicity. Here we summarize those experimental techniques indicating their applicability at different stages of the research, as well as pointing out their strengths, advantages, drawbacks and limitations. Also, the existing strategies and approaches are critically reviewed with the objective to reveal and give rise to the development of the analytical methodology suitable for reliable Pt-based DTDSs characterization which would eventually result in novel therapies and better patients' outcomes.

Endovascular interventions for arteriovenous fistula (AVF) and graft (AVG) can cause significant pain and discomfort to the patients and adequate sedation and analgesia are often required; hence it is important for the interventionist to understand and appreciate some of the basic principles of sedation and anesthesia. In particular, many patients with ESRD have co-morbidities that may put them at risk of cardiac events during sedation and anesthesia. As such, proper assessment of patient and putting in place a robust crisis management plan is critical in the smooth operation of the intervention suite.