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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
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IR REFERENCE GUIDE FOR ORDERING
OUTPATIENT PROCEDURES
TABLE OF CONTENTS (con’t.)
41. Venogram
42. Vertebroplasty
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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