Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
INTERVENTIONAL RADIOLOGY REFERENCE GUIDE FOR IR PROCEDURE ORDER SETS IR REFERENCE GUIDE FOR ORDERING OUTPATIENT PROCEDURES TABLE OF CONTENTS 1. Aneursym Coiling 2. Abscess Drain 3. Adrenal Vein Sampling 4. Arteriogram 5. Biliary Drain Placement (PTC) 6. Biliary Tube Change 7. Carotid Stent 8. Cisternogram 9. Central Venous Catheter (CVC) 10. Discogram 11. Facet Injections 12. Fine Needle Aspiration (FNA) 13. HSG/Tubal Cannulation 14. IJ Change 15. IJ Pull or Check 16. IVC Filter 17. Kyphoplasty 18. Lumbar Puncture 19. Microwave Ablation 20. Myelogram 21. Nephrostomy 22. Nerve Blocks 23. Paracentesis 24. PEG Tube Placement 25. Pelvic Vein Congestion/Ovarian Vein Embolization 26. Percutaneous Biopsy 27. Percutaneous Sclerotherapy 28. Petrosal Vein Sampling 29. Pleurex Drain 30. Port Placement 31. Shuntogram/Fistulogram 32. Trans Arterial Chemo Embolization 33. Thoracentesis 34. Thrombolytic Therapy 35. TIPS 36. TIPS Check 37. TransJugular Liver Biopsy 38. Tunneled IJ Placement 39. Uterine Artery Embolization 40. Vasopressin Intra-arterial Infusion Pg. 1 Pg. 1 Pg. 1 Pg. 2 Pg. 2 Pg. 2 Pg. 2 Pg. 3 Pg. 3 Pg. 3 Pg. 3 Pg. 3 Pg. 4 Pg. 4 Pg. 4 Pg. 4 Pg. 4 Pg. 5 Pg. 5 Pg. 5 Pg. 5 Pg. 6 Pg. 6 Pg. 6 Pg. 6 Pg. 7 Pg. 7 Pg. 7 Pg. 7 Pg. 8 Pg. 8 Pg. 8 Pg. 8 Pg. 9 Pg. 9 Pg. 9 Pg. 9 Pg. 10 Pg. 10 Pg. 10 IR REFERENCE GUIDE FOR ORDERING OUTPATIENT PROCEDURES TABLE OF CONTENTS (con’t.) 41. Venogram 42. Vertebroplasty Pg. 10 Pg. 10 A. B. C. D. E. F. G. Pg. 11 Pg. 11 Pg. 12 Pg. 12 Pg. 13 Pg. 13 Pg. 13 Medication Guidelines Contrast Allergy Cardiac Patients Laboratory Parameters Diabetic Patients NPO Status for Procedures Breastfeeding and Contrast IR REFERENCE GUIDE Arrival time before scheduled appointment a. Anesthesia case- arrive 2 hr before scheduled time If patient seen in PAT clinic check in 90 minutes before procedure b. If admitted after the procedure, check in at admitting 90 minutes before c. If OP Lab needed before case, present 90 min before procedure All patients with renal impairment, liver disease, thrombocytopenia, or are currently taking anticoagulant therapy must have CBC, INR and Chem 12 less than 1 week old. Aneurysm Coiling Endovascular coils placed in intracranial aneurysms provides a minimally invasive alternative to surgical clipping Requires outpatient consult prior to scheduling NPO per anesthesia-pt will have general anesthesia for procedure (intubated and paralyzed) ICU reservation required…admitted by neurosurgery or neurology Pt will stay 1-2 days post procedure. Pt will stay longer if they present with a Subarachnoid hemorrhage IF patient is going to have a stent….Pt MUST be on ASA 325mg and Plavix 75mg po for 5 days pre procedure and a special consent must be signed Abscess Drain Involves placement of a catheter using CT, fluoroscopy or ultrasound for fluid drainage NPO per IR Standards Outpatient procedure –extended recovery or possible overnight stay Arrange driver *Note-pt may need antibiotic coverage post procedure if ordering physician has not already initiated. If flushes are ordered – send flushes home with pt Adrenal Vein Sampling Is to localize an adrenal aldenoma by sampling blood for aldosterone and cortisol from both adrenal veins and the IVC. An adrenal adenoma can lead to uncontrolled hypertension and hypokalemia. Needs to be set up by nurse clinician NPO per IR Standards Outpatient-extended recovery…pt stays 2 hours post procedure Arrange driver 1 Arteriogram – Involves the injection of contrast into arteries to evaluate the vessels and diagnose vascular disease. This exam may lead to interventional procedures such as angioplasty, embolization or stent placement. NPO per IR Standards Arrange driver Recovery time: 2 hrs if closure device used, 6 hrs for manual pressure. Coumadin, Aspirin, and Plavix must be held 3-5 days prior to procedure. Lovenox - hold 12hrs prior to procedure. (Notify IR physician or patient’s primary care provider for specific instructions if holding medications are contraindicated) Biliary Drain Placement (PTC)-New Drain placement used for evaluation of a bile leak or determine cause of obstructions to the flow of bile NPO per IR Standards Overnight stay post procedure required / 23 hour admit Required labs- CMP, INR Procedure CANNOT be performed if patient has ascites…ascites must be drained first – Paracentesis must also be ordered at time of drain placement Antibiotics 3 days pre and 3 days post-preferred is Levaquin 500mg daily Alternatively, Cipro 500mg BID may be used If pt’s have not been treated w/antibiotics for 3 days pre procedure then IV Zosyn 3.375mg will be given 1 hr pre procedure If flushes are ordered, send flushed home with patients. Biliary Tube Change NPO per IR Standards Outpatient procedure Arrange driver Antibiotics 3 days pre and 3 days post-preferred is Levaquin 500mg daily Alternatively Cipro 500mg BID may be used If pt’s have not been treated w/antibiotics for 3 days pre procedure then IV Zosyn 3.375mg will be given 1 hr pre procedure If flushes are ordered, send flushes home with patients. Carotid Stent Stent placement when medical management is insufficient. Treatment for symptomatic TIAs or strokes. Also for asymptomatic auscultating carotid bruit NPO per IR Standards Arrange driver Inpatient-ICU reservation under (usually 1-2 day stay post) Pt MUST be on ASA 325mg and Plavix 75mg po for 6 days pre and needs to take them the morning of procedure Pt’s will usually have an outpatient consult prior to procedure 2 Cisternogram To determine if there is abnormal CSF flow within the brain and spinal canal to determine hydrocephalus Two Types need to specify and confirm with Nuc Med or CT Confirm procedure with Nuc Med NPO per IR Standards Outpatient procedure Arrange driver Central Venous Catheter (CVC) NPO per IR Standards Outpatient procedure Arrange driver Instruct patient to wash with Hibiclens the night before and the morning of the procedure. If unable to use Hibiclens, request that patient substitute antimicrobial soap. Discogram Involves the injection of contrast into the intervetebral disc to determine the exact location of pain NPO per IR Standards Outpatient procedure. Arrange driver. Ancef 1 gm pre procedure. Keep patient 30 min post procedure. No restriction on positioning after procedure. CT needed post procedure Facet Injections Involves the injection of a steroid and or an anesthetic into the facet joint to decrease inflammation and reduce pain NPO per IR Standards Outpatient procedure Arrange driver Keep 30 min post procedure Fine Needle Aspiration (FNA) To obtain a tissue core and or fine needle cell aspiration for diagnosis . Some indications include diagnosis of primary tumor, benign process, confirmation of metastasis and cancer staging NPO per IR Standard Arrange driver FNA – Lung CXR immediate post procedure and in 1 hrs…if no pneumo then D/C’d FNA- Liver Pt to stay 2-4 hours post procedure 3 HSG/Tubal Cannulation For treatment of primary and secondary infertility r/t tubal blockage NPO per IR Standards Outpatient procedure Arrange driver MUST be scheduled on day 7-10 of cycle Must be on Doxycycline 100mg daily for 2 days pre and 2 days post procedure Cannot be actively bleeding or spotting IJ Change NPO per IR Standards Outpatient procedure. Arrange driver. Instruct patient to wash with Hibiclens the night before and the morning of the procedure. If unable to use Hibiclens, request that patient substitute antimicrobial soap. IJ Pull or Check NPO per IR Standards Outpatient procedure Arrange driver Instruct patient to wash with Hibiclens the night before and the morning of the procedure. If unable to use Hibiclens, request that patient substitute antimicrobial soap. IVC Filter Involves the placement of a filter into the inferior vena cava to prevent pulmonary embolus NPO per IR Standard Outpatient procedure - Prolonged recovery, approx 2 hours post procedure Arrange driver Kyphoplasty – Involves inserting a needle into the vertebral body inflating a balloon which creates a cavity and injection of a cement substance. Used to treat painful, progressive vertebral compression fractures and restore the vertebral body height NPO per IR Standards Outpatient procedure - Prolonged recovery, approx. 2-4 hours post procedure ALL pt’s need to have CONSULT prior with the exception of Dr. Burton’s patients Ancef 1 gm IV pre-procedure 4 Lumbar Puncture Involves the insertion of a needle into the spinal canal to administer medications or obtain fluid for diagnosis Orders needed if fluids to be sent to lab NPO per IR Standards Outpatient procedure - Prolonged recovery, approx 1-2 hours Arrange driver. HOLD Plavix for 5 days pre-procedure. Lie flat in recovery x 1 hour. Instruct patient to remain flat or HOB > 30 degrees. For an additional 6 hours after returning home. If patient develops headache Then have them lie flat for 24hours except BRP. Encourage patient to drink caffeine. If HA continues – contact IR Microwave Ablation Is a thermal therapy that uses heat to coagulate tissue and achieve cellular kill. An ablation is delivered percutaneously and placed into a tumor Requires outpatient consult prior to scheduling NPO per IR Standards All cases done by anesthesia Overnight stay post procedure required FYI-pacemakers must be turned off during procedure (obtain magnet to disable) Labs required: CBC, INR, CMP PLT > 50 INR < 1.9 CR < 1.9 Myelogram Involves the injection of contrast using fluoroscopy into the spinal subarachnoid space. It is used to determine a tumor, herniated disc, arachnoiditis or nerve root injury. NPO per IR Standards Outpatient procedure - Prolonged recovery, approx. 1-2 hours CT scan post procedure required Arrange driver. Lie at 45˚ angle x 1 hour in recovery after procedure. Encourage patient to remain 45˚ for an additional 6 hours at home. If patient develops headache then they should lie flat for 24 hours except BRP. Encourage patient to drink caffeine If HA continues – contact IR Nephrostomy Placement-New – an external drain placed in the kidney NPO per IR Standards Arrange driver Overnight stay post procedure usually required / 23hour admit. Required labs BMP CR < 1.4 FYI-routine tube change is every 3 months Antibiotics 3 days pre and 3 days post-preferred is Levaquin 500mg daily Alternatively, Cipro 500mg BID may be used If pt’s have not been treated w/antibiotics for 3 days pre procedure then IV Levaquin 500 mg will be given 1 hr pre procedure 5 Nephrostomy Tube Change NPO per IR Standards Arrange driver Outpatient Procedure Antibiotics 3 days pre and 3 days post-preferred is Levaquin 500mg daily Alternatively, Cipro 500mg BID may be used If pt’s have not been treated w/antibiotics for 3 days pre procedure then IV Levaquin 500mg will be given 1 hr pre procedure. Routine change is every 3 months. Nerve Blocks Involves the injection of a steroid or anesthetic to treat pain NPO per IR Standards Outpatient procedure Arrange driver Paracentesis Insertion of a needle into the abdominal cavity to drain fluid and or obtain fluid specimen for diagnosis Order needed for labs to be sent on fluid NPO per IR Standard Outpatient procedure Arrange driver Follow Albumin replacement protocol - see Albumin flowsheet Peg Tube Placement Tube placed into the stomach for nutritional support and or medications NPO per IR Standards Outpatient procedure Arrange driver FYI-if new placement-NG tube will be placed during procedure, if just a changeNo NG placement needed NPO 12 hour post procedure. Advance diet as tolerated. Pelvic Vein Congestion/ Ovarian Vein Embolization Occlusion of blood flow to the veins causing pelvic congestion Requires outpatient consult prior to scheduling NPO per IR Standards Arrange Driver Overnight stay post procedure Colace 100 mg PO BID 1 week prior to procedure Fleets enema evening prior to procedure Cannot be actively bleeding or spotting 6 Percutaneous Biopsy Involves needle placement under fluoroscopy, ultrasound or CT guidance to obtain a tissue core and or a fine needle aspiration for diagnosis FILMS MUST BE APPROVED PRIOR TO SCHEDULING NPO per IR Standard Outpatient-extended recovery-if superficial lesion then extended recovery not required Arrange driver Lung CXR immediate post procedure and in 1 hrs…if no pneumo then D/C’d Liver Pt to stay 2-4 hours post procedure Renal Pt to stay 6-8 hours post procedure with possible admission Percutaneous Sclerotherapy Involves the injection of a sclorosing agent such as alcohol into a vein. Used to treat venous malformation and hemagiomas *Note-most pt’s will need IR consult prior to scheduling *Note-pt’s may require multiple treatments-usually waiting 4-6 weeks between NPO per IR Standards Overnight stay post procedure required Pain mgt per PCA (usually Dilaudid) Usually pts get general anesthesia Petrosal Vein Sampling For patients who are suspected of having a pituitary tumor resulting in Cushings Syndrome Nurse Clinician will be arranging these procedures NPO per IR Standards Outpatient-extended recovery Arrange driver Carefully review meds for any possible interaction with hormone used in procedure *Note-we must have CRH (corticotrophin releasing hormone) on hand Pleurex Drain Tunneled catheter placed in lung or abdomen which will allow for drainage of fluid. Used for long term care. NPO per IR Standard Arrange driver Bring primary care giver with pt day of drain placement for review of catheter Ask if pt has received a call from Edgepark if not inform them they need to contact ordering physician’s to have them fill out paper work for supply delivery CXR immediate post procedure and 1 hour after If no pneumothorax – ok to discharge 7 Port Placement A central line catheter that has its tip in the central circulation. Catheter is placed for long term use of antibiotics, chemotherapy, total parental nutrition administration and multiple frequent blood draws NPO per IR Standards Outpatient procedure Arrange driver Ancef 1 gm IV prior to procedure Instruct patient to wash with Hibiclens the night before and the morning of the procedure. If unable to use Hibiclens, request that patient substitute antimicrobial soap. Shuntogram/Fistulogram – Involves accessing a shunt/fistula and injection of contrast under flouroscopy to identify a stricture or occlusion. Angioplasty and/or thrombolytic therapy (TPA and Heparin) may be utilized to restore patency. NPO per IR Standard Outpatient procedure. Arrange driver Must go to dialysis after procedure. Make sure dialysis consent is signed before procedure. Call dialysis and confirm that patient is on their schedule. OK for pt. to continue taking ASA and Plavix. Cannot do if infected. If new shunt then must wait 6wks after initial placement to use. Trans Arterial Chemo Embolization Catheter directed delivery of chemotherapy agent and particles with intention of treating hepatic tumors Requires outpatient consult prior to scheduling Make sure staff MD sees pt prior to going into room NPO per IR Standards Labs required - CBC, INR, CMP INR < 1.9 PLTS > 50 BILI < 3 Make sure there is an order for chemo Overnight stay post procedure Thoracentesis Insertion of a needle into the pleura to drain or obtain fluid specimen for diagnosis Order needed for labs to be sent on fluid NPO per IR Standard Outpatient procedure Arrange driver CXR immediately post procedure and 1 hour after If no pneumothorax – ok to discharge 8 Thrombolytic Therapy Involves the infusion of a thrombolytic agent (TPA urokinase) into a vein or artery to dissolve blood clots NPO per IR Standards ICU admission post procedure Required labs-CBC, Chem 7, INR, Fibrinogen Parameters Venous—INR<=2.5 Platelets>=50,000 Arterial—INR<=1.9 Platelets >=50,000 If high likelihood of thrombolysis, order TPA prior to start of case. TIPS Involves the creation of a shunt between the hepatic and portal vein via a jugular access. Transjugular intrahepatic portosystemic shunts are an alternative to conventional portocaval shunting in patients with advanced liver disease, portal hypertension or recurrent hemorrhage from esophageal varices Requires outpatient consult prior to scheduling NPO per IR Standards Overnight stay post procedure required Required labs-CBC, CMP, INR. PLT > 50 INR < 1.9 CR < 1.4 Bili < 2 MELD < 20 MELD score predicts survival rate Pt must have had sono pre procedure for baseline, 2 weeks following procedure and every 3 months Hepatology consult required Obtain consent for Paracentesis, TIPS and possible Variceal Embolization TIPS Check NPO per IR Standard Outpatient procedure…pt to stay 1 hour post procedure Arrange driver Required labs-CBC, CMP, INR PLT > 50 INR < 1.9 CR < 1.4 Bili < 2 TransJugular Liver Biopsy Involves the placement of a central venous catheter into the jugular vein. That catheter is then passed into the liver to obtain a tissue core or a fine needle aspiration for diagnosis NPO per IR Standards Outpatient-extended recovery Arrange driver Required labs-CBC, CMP, INR INR < 2.0 PLT > 50 CR < 1.4 9 Tunneled IJ Placement Involves the placement of a central venous catheter which is tunneled under the skin for long term use The catheter is used for venous access for the administration of drugs, fluids, nutrition and blood products. NPO per IR Standards Outpatient procedure. Arrange driver. Ancef 1 gm IV prior to procedure. Instruct patient to wash with Hibiclens the night before and the morning of the procedure. If unable to use Hibiclens, request that patient substitute antimicrobial soap. Uterine Artery Embolization Involves an arteriogram and embolization of the uterine arteries. This procedure is done to treat fibroid tumors which cause heavy bleeding and pelvic pain Requires outpatient consult prior to scheduling NPO per IR Standards Pre-procedure MRI required Pt to arrive 2 hours pre procedure Extended recovery admission Antibiotics-pt’s will receive IV Levaquin 500mg prior to procedure and will take Levaquin 500mg po daily for 5 days post procedure Follow up sono: 1 week, 6 month, and 1 year post procedure Vasopressin Intra-arterial Infusion – Involves the injection of vasopressin intra-arterial for the treatment of uncontrolled bleeding. NPO per IR Standards Pt will be admitted after procedure…ICU admit only Standard dosage 0EM 7.2units and increase to 0.4units/min then recheck after 2 hours Venogram Involves the injection of contrast into the vein for dx of many diseases such as DVT venous malformations, and venous stenosis NPO per IR Standards Outpatient procedure Arrange driver Follow IV contrast protocol for checking creatinine Vertebroplasty Involves inserting a needle into the vertebra and injection of a cement substance It is used to treat painful, progressive vertebral compression factures. NPO per IR Standards Arrange driver Ancef 1 gram IV pre procedure Outpatient procedure…pt must stay 2 hours post procedure ALL pt’s need to have CONSULT prior with the exception of Dr. Burton’s patients 10 MEDICATION GUIDELINES MEDICATION GUIDELINES ASA- Hold 3-5 days pre procedure Lovenox-Hold for 12 hrs pre procedure (ask physician how long to hold post procedure) Persantine-Do Not Hold Plavix-Hold 3-5 days pre procedure Ticlid-Hold 3-5 days pre procedure Coumadin-usually hold for 3-5 days pre procedure (ask primary physician) Pradaxa-usually hold for 3-5 days pre procedure (ask primary physician) Aggrenox – usually hold for 3-5 days pre procedure (ask primary physician) Heparin-hold 1 hr pre procedure (ask physician how long to hold post procedure) FYI-physician will normally want pts to take any essential meds w/water the day of the procedure i.e. cardiac meds, blood pressure meds, seizure meds CONTRAST ALLERGIES CONTRAST ALLERGY ***If ANY history or questionable contrast hx reaction follow these protocols*** Have patient contact ordering physician for premedications Standard Premedication Methylprednisolone 32mg po 12 hrs and 2 hrs pre procedure-Preferred OR Prednisone 40mg po 12hrs and 2 hrs pre procedure Benadryl 50 mg po 1 hour pre procedure 11 CARDIAC PATIENTS PROPHYLACTIC ANTIBIOTICS FOR CARDIAC PTS (pts who have had a valve replaced) Contact primary care physician Mitral valve disease or replacement=needs pretx w/antibiotics Aortic valve disease or replacement=No need to pretx LABORATORY PARAMETERS Labs required on all patients with renal impairment, liver disease, thrombocytopenia, and currently taking blood thinners. INR Venous procedures INR<=2.5 Arterial procedures INR<=1.9 Percutaneous Biopsy INR <=1.9 FYI for pt’s having either arterial procedures of percutaneous biopsies INR >=1.9 but <=2.5 then FFP (Fresh Frozen Plasma) infusion Required immediately before or during procedure (no recheck required) INR>2.5 Discussed on a case by case basis with IR physician CREATININE For procedures using contrast notify physician if Creat >=1.2 Physician may want to have pt admitted for hydration and possibly Treat w/ Mucomyst-usual dosage 600mg po BID for 1 day pre, day of procedure and 1 day post procedure PLATELETS Arterial procedures and Percutaneous Biopsies Platelets>=50,000 ok for procedure Platelets <50,000 require platelet transfusion Immediately before and/or during procedure-check with physician Platelets <25,000 will need to be discussed between IR MD and referring team Venous procedures Platelets>=50,000 ok for procedure Platelets<50,000 discussed on case by case basis with IR physician 12 DIABETIC PATIENTS DIABETIC PATIENTS Need to contact primary physician for medication dosage. Metformin should be held 24 hours prior and 48 hours post procedure if contrast is given IV or IA Restarting medications needs to be managed by primary physician Post procedure renal function tests should be assessed NPO STATUS FOR PROCEDURES NPO STATUS FOR IR PROCEDURES AM PROCEDURES – NPO AFTER MIDNIGHT EXCEPT FOR MEDICATIONS WITH SIPS OF WATER 1200 OR AFTER PROCEDURES – PATIENT MAY EAT A SLICE OF DRY TOAST WITH A CUP OF TEA, COFFEE, OR WATER BEFORE 0800. THE PATIENT IS TO BE NPO AFTER 0800 AND TO TAKE THEIR AM MEDICATIONS BREASTFEEDING AND CONTRAST BREASTFEEDING – PATIENTS RECEIVING CONTRAST Have patient pump prior to procedure. After procedure, it is recommended that patient pump and waste breast milk for 24 hours. 13