Difference between revisions of "I need a procedure"
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| − | == | + | ==I need a procedure: Steps for ordering clinicians== |
| − | + | 1. Determine which radiology division to call, and how to call them. | |
| − | + | ||
| − | + | ||
| − | + | ||
| − | + | ||
| − | + | ||
| − | == Who to | + | 2. Contrast allergy prep needed? |
| − | === | + | |
| − | + | 3. Labs obtained? | |
| − | *Tunneled central | + | |
| − | * | + | 4. Determine procedural bleeding risk, manage anticoagulation/anti-platelet medications, and correct for Plt and INR goal. |
| − | + | ||
| + | ''The Radiologist will discuss #2 through #4 with you.'' | ||
| + | |||
| + | == Who and How to Call: Body, VIR, GI, Neuro, Peds, MSK, or Chest == | ||
| + | ===[https://docs.google.com/spreadsheets/d/1HRS1m1oEDTWGatOQg07zLdlaJfM6G91zmAzB83bcWGA/edit#gid=1117733968 Who to Call Spreadsheet] & [https://docs.google.com/spreadsheets/d/1_-NkLTiYR70_rWGI4X2S74GP1QkruqMGBy4XwsCkZ3w/edit?usp=sharing Procedure Orders Spreadsheet]=== | ||
| + | |||
| + | * Imaging-guided interventions are provided by several radiology sections, the details and appropriate contacts for which are in the '''[https://docs.google.com/spreadsheets/d/1HRS1m1oEDTWGatOQg07zLdlaJfM6G91zmAzB83bcWGA/edit#gid=1117733968 above spreadsheet]''' and text below (consider using the search function for quick navigation). | ||
| + | * Placing an imaging-guided procedure order will be needed ('''[https://docs.google.com/spreadsheets/d/1_-NkLTiYR70_rWGI4X2S74GP1QkruqMGBy4XwsCkZ3w/edit?usp=sharing the most common of which are here]'''), but this order alone will NOT generate a page to the appropriate section; you'll need to follow the section-specific steps below to make sure the appropriate team is aware of the request | ||
| + | |||
| + | ==Contrast Allergy Prep== | ||
| + | '''13 hr prep (Greenberger protocol)''' : Prednisone 50mg PO q6 hrs x 3: 13hrs, 7hrs, and 1hr prior to scan, and Benadryl 50 mg IV 1 hr prior to scan (scan should be performed within 6hrs of last dose). | ||
| + | |||
| + | '''Emergency 4hr prep''': Solumedrol 60mg IV IV 4hrs prior to exam, and another dose right before exam. Benadryl 25-50mg IV 1 hr prior to exam per radiologist. | ||
| + | |||
| + | '''Questions''': Reading rooms are staffed between 7:30am and 5:00pm; for after hours questions call the Jr Call phone at 684-4475 | ||
| + | |||
| + | == Peri-procedural Anticoagulation Guidelines == | ||
| + | |||
| + | '''1. Determine procedure bleeding risk''' (low or high; see Bleeding Risk Categorization below) | ||
| + | |||
| + | '''2. Determine needed labs and Platelet/INR goals''' (see Laboratory Values below). | ||
| + | |||
| + | '''3. Refer to anticoagulation guidelines based on procedure risk category''' (see Management of Medications below). | ||
| + | |||
| + | These guidelines, based on the 2019 Society of Interventional Radiology consensus guidelines, have been reviewed and approved by all Duke IR attending physicians, but final decision is at the discretion of the attending physician or APP responsible for the case, as patient circumstances and procedural details can result in varying risk. For urgent circumstances, benefit of proceeding may outweigh risks of bleeding – furthermore, reversal agents may be available. For full details, please refer to the source document, available at http://sites.duke.edu/dukeir. | ||
| + | |||
| + | '''For Neuroradiology Division guidelines''' (LP, spine biopsy, etc), see this document (updated July 2024): [[File:Anticoagulation Therapy Duke Spine Intervention July 2024.pdf]] | ||
| + | |||
| + | == Procedural Bleeding Risk Categorization == | ||
| + | |||
| + | [[File:Procedural_Bleeding_Risk_2024.png|500px]] | ||
| + | |||
| + | == Pre-procedural Laboratory Values == | ||
| + | |||
| + | [[File:Lab values.png|700px]] | ||
| + | |||
| + | |||
| + | == Management of Anticoagulation and Antiplatelet Medications == | ||
| + | |||
| + | '''Low Bleeding Risk Procedures:''' | ||
| + | *If on warfarin, withold for 2-5 days if <u>INR > 3.0</u>. For all other listed medications below, <u>do not withold.</u> | ||
| + | |||
| + | '''High Bleeding Risk Procedures:''' | ||
| + | |||
| + | [[File:Management AC.png|700px]] | ||
| + | |||
| + | |||
| + | == Special Cardiology Medications with High Risk Procedures == | ||
| + | |||
| + | [[File:Special AC meds.png|700px]] | ||
| + | |||
| + | ==VIR (Vascular & Interventional Radiology)== | ||
| + | '''CONTACT:''' Vascular IR pager ('''970-7930''') | ||
| + | |||
| + | '''HOURS:''' Routinely in-house from 6:30am - 6:30pm, and available overnight for urgent and emergent consults (home call system) | ||
| + | |||
| + | '''PROCEDURES''' | ||
| + | *Tunneled central lines (placements and bedside removals) | ||
| + | *Visceral and pulmonary arteriograms and intervention | ||
| + | *Percutaneous GTube / GJ Tube / J Tubes | ||
| + | *Percutaneous nephrostomy / biliary / cholecystostomy tubes (PCNs, PBDs, PercCholes) | ||
*IVC filter placements and removals | *IVC filter placements and removals | ||
| − | *AVF / AVG fistulagrams | + | *AVF / AVG fistulagrams and interventions |
| − | + | *Solid organ tumor ablations and embolizations | |
| − | + | ||
| − | *Solid organ | + | |
| − | + | ||
*Vertebral kyphoplasty and sacroplasty | *Vertebral kyphoplasty and sacroplasty | ||
*Venous and arterial malformation percutaneous treatment | *Venous and arterial malformation percutaneous treatment | ||
| − | + | Of note, VIR does not place PICC lines (contact PICC team), and generally does not place or pull inpatient non-tunneled central lines (contact medical procedure team). | |
| − | Of note, | + | |
| + | ==Body Procedures== | ||
| + | '''CONTACT & HOURS:''' Mon-Fri 7:30 am to 5:00 pm '''206-3465''' (Body IR pager). If emergent procedure is required between 5:00 pm and 10:00 pm Monday-Friday, or 7:30 am to 12:00 pm on weekends/holidays, please call the Body reading room ('''684-7224'''). If emergent intervention is required overnight, please call the Radiology Senior Call phone ('''681-4422'''). | ||
| − | + | '''PROCEDURES:''' | |
| − | + | *Intraabdominal and superficial soft tissue drain placement and aspiration (U/S and CT-guided) | |
| − | * | + | *Percutaneous solid organ and other intraabdominal biopsies, both targeted and random (U/S and CT-guided) |
| − | + | *Lumbar level paravertebral abscesses drainage | |
| − | * | + | |
*See 'GI / GU Fluoroscopy' for information on Dobhoff tubes, esophograms, upper GI exams, contrast enemas, etc | *See 'GI / GU Fluoroscopy' for information on Dobhoff tubes, esophograms, upper GI exams, contrast enemas, etc | ||
| + | ==GI / GU Fluoro Studies== | ||
| + | '''CONTACT & HOURS:''' Monday-Friday 7:30am-5:00pm '''684-7257'''; urgent procedures 7:30am - 12:00 pm on the weekend '''684-7224''' (body reading room); emergent procedure after 5pm Monday-Friday '''681-4475''' (Jr Call phone) | ||
| − | + | '''PROCEDURES:''' | |
| − | + | *Imaging-guided Dobhoff tube placements (after failed attempt on floor) | |
| − | *Imaging-guided Dobhoff tube placements ( | + | |
*Esophagrams, Upper GI studies (evaluate through the ligament of Trietz), and small bowel follow throughs (for intestinal motility) | *Esophagrams, Upper GI studies (evaluate through the ligament of Trietz), and small bowel follow throughs (for intestinal motility) | ||
*Contrast enemas (water-soluble contrast for leaks, barium for pre G-tube placement) | *Contrast enemas (water-soluble contrast for leaks, barium for pre G-tube placement) | ||
| Line 41: | Line 94: | ||
*For similar exams but in the pediatric patients, please see 'Pediatric Fluoroscopic Studies' for more information | *For similar exams but in the pediatric patients, please see 'Pediatric Fluoroscopic Studies' for more information | ||
| + | ==Pediatric Fluoro Studies== | ||
| + | '''CONTACT & HOURS:''' '''684-7288''' 7:30 am to 5:00 pm Mon-Fri and 7:30 am to 12:00 pm on the weekend. Emergent after hours studies available by calling Radiology Junior Call phone ('''681-4475''') | ||
| − | + | '''PROCEDURES:''' | |
| − | + | *Fluorscopic upper GI exams (evaluate for malrotation, upper GI pathology) and contrasted enemas | |
| − | *Fluorscopic upper GI exams (evaluate for malrotation, upper GI pathology) | + | *Fluoroscopic Dobhoff tube placement |
| − | *Fluoroscopic GTube / GJ tube checks | + | *Fluoroscopic percutaneous GTube / GJ tube checks |
*Intussusception reductions | *Intussusception reductions | ||
| + | ==Neuroradiology Interventions== | ||
| + | '''CONTACT & HOURS:''' For fluoroscopic guided LPs after failed bedside attempt, Mon-Fri 7:30am-5pm pager '''206-9959'''. For all other procedures and for urgent procedures between 5:00 pm and 10:00 pm Monday-Friday, or 7:30 am - 12:00 pm on the weekend, call '''684-7213''' (neuro reading room). If emergent intervention is needed overnight, please call '''681-4422''' (Sr call phone). | ||
| − | + | '''PROCEDURES:''' | |
| − | + | *Fluoroscopic guided lumbar punctures (following failed bedside LP attempt) - pager 206-9959 during business hours | |
| − | *Fluoroscopic guided lumbar punctures (following failed bedside LP | + | |
*Myelograms | *Myelograms | ||
| − | * | + | *For CSF-leak related interventions, please call the neuroradiology reading room at 684-7213. |
| − | * | + | *For vertebral body / disc aspiration, please call the neuroradiology reading room at 684-7213. |
| + | *For paravertebral abscess drainage, contact the Thoracic Interventions(see below) for thoracic level abscesses and Body Procedures (see above) for lumbar level disease. | ||
| + | |||
| + | ==Neurovascular Interventional Radiology== | ||
| + | Neurovascular IR is staffed by neurosurgery, and can be reached at the functional pager '''970-2671'''. Neurovascular interventions include: | ||
| + | *Intracranial vasculature occlusion suction thrombectomy | ||
| + | *Intracranial aneurysm embolization | ||
| + | ==Musculoskeletal Interventions== | ||
| + | '''CONTACT & HOURS''': Routinely available from 7:30 am to 5:00 pm Mond-Fri by calling the MSK reading room ('''684-7247'''). If emergent intervention is required between 5:00 pm and 7:30 am or on the weekend, please call the Radiology Senior Call phone ('''681-4422'''). | ||
| − | + | '''PROCEDURES''': | |
| − | + | *Fluoroscopy guided bone biopsies, marrow aspiration | |
| − | * | + | |
*Shoulder and hip arthrograms and aspirations | *Shoulder and hip arthrograms and aspirations | ||
| + | ==Thoracic Interventions== | ||
| + | '''CONTACT & HOURS''' Routinely available 7:30 am to 5:00 pm Mon-Fri by calling the CTI reading room ('''684-7419'''). If emergent intervention is required outside of these hours, please call the Radiology Senior Call phone ('''681-4422'''). | ||
| − | + | '''PROCEDURES:''' | |
| − | + | ||
*Lung / mediastinal / pleural biopsy not accessible by interventional pulmonology | *Lung / mediastinal / pleural biopsy not accessible by interventional pulmonology | ||
*CT guided thoracentesis / chest tube placement if not successful by ultrasound approach with interventional pulmonology | *CT guided thoracentesis / chest tube placement if not successful by ultrasound approach with interventional pulmonology | ||
| + | *Thoracic level paravertebral abscesses drainage | ||
Latest revision as of 12:33, 9 October 2024
Contents
- 1 I need a procedure: Steps for ordering clinicians
- 2 Who and How to Call: Body, VIR, GI, Neuro, Peds, MSK, or Chest
- 3 Contrast Allergy Prep
- 4 Peri-procedural Anticoagulation Guidelines
- 5 Procedural Bleeding Risk Categorization
- 6 Pre-procedural Laboratory Values
- 7 Management of Anticoagulation and Antiplatelet Medications
- 8 Special Cardiology Medications with High Risk Procedures
- 9 VIR (Vascular & Interventional Radiology)
- 10 Body Procedures
- 11 GI / GU Fluoro Studies
- 12 Pediatric Fluoro Studies
- 13 Neuroradiology Interventions
- 14 Neurovascular Interventional Radiology
- 15 Musculoskeletal Interventions
- 16 Thoracic Interventions
I need a procedure: Steps for ordering clinicians
1. Determine which radiology division to call, and how to call them.
2. Contrast allergy prep needed?
3. Labs obtained?
4. Determine procedural bleeding risk, manage anticoagulation/anti-platelet medications, and correct for Plt and INR goal.
The Radiologist will discuss #2 through #4 with you.
Who and How to Call: Body, VIR, GI, Neuro, Peds, MSK, or Chest
Who to Call Spreadsheet & Procedure Orders Spreadsheet
- Imaging-guided interventions are provided by several radiology sections, the details and appropriate contacts for which are in the above spreadsheet and text below (consider using the search function for quick navigation).
- Placing an imaging-guided procedure order will be needed (the most common of which are here), but this order alone will NOT generate a page to the appropriate section; you'll need to follow the section-specific steps below to make sure the appropriate team is aware of the request
Contrast Allergy Prep
13 hr prep (Greenberger protocol) : Prednisone 50mg PO q6 hrs x 3: 13hrs, 7hrs, and 1hr prior to scan, and Benadryl 50 mg IV 1 hr prior to scan (scan should be performed within 6hrs of last dose).
Emergency 4hr prep: Solumedrol 60mg IV IV 4hrs prior to exam, and another dose right before exam. Benadryl 25-50mg IV 1 hr prior to exam per radiologist.
Questions: Reading rooms are staffed between 7:30am and 5:00pm; for after hours questions call the Jr Call phone at 684-4475
Peri-procedural Anticoagulation Guidelines
1. Determine procedure bleeding risk (low or high; see Bleeding Risk Categorization below)
2. Determine needed labs and Platelet/INR goals (see Laboratory Values below).
3. Refer to anticoagulation guidelines based on procedure risk category (see Management of Medications below).
These guidelines, based on the 2019 Society of Interventional Radiology consensus guidelines, have been reviewed and approved by all Duke IR attending physicians, but final decision is at the discretion of the attending physician or APP responsible for the case, as patient circumstances and procedural details can result in varying risk. For urgent circumstances, benefit of proceeding may outweigh risks of bleeding – furthermore, reversal agents may be available. For full details, please refer to the source document, available at http://sites.duke.edu/dukeir.
For Neuroradiology Division guidelines (LP, spine biopsy, etc), see this document (updated July 2024): File:Anticoagulation Therapy Duke Spine Intervention July 2024.pdf
Procedural Bleeding Risk Categorization
Pre-procedural Laboratory Values
Management of Anticoagulation and Antiplatelet Medications
Low Bleeding Risk Procedures:
- If on warfarin, withold for 2-5 days if INR > 3.0. For all other listed medications below, do not withold.
High Bleeding Risk Procedures:
Special Cardiology Medications with High Risk Procedures
VIR (Vascular & Interventional Radiology)
CONTACT: Vascular IR pager (970-7930)
HOURS: Routinely in-house from 6:30am - 6:30pm, and available overnight for urgent and emergent consults (home call system)
PROCEDURES
- Tunneled central lines (placements and bedside removals)
- Visceral and pulmonary arteriograms and intervention
- Percutaneous GTube / GJ Tube / J Tubes
- Percutaneous nephrostomy / biliary / cholecystostomy tubes (PCNs, PBDs, PercCholes)
- IVC filter placements and removals
- AVF / AVG fistulagrams and interventions
- Solid organ tumor ablations and embolizations
- Vertebral kyphoplasty and sacroplasty
- Venous and arterial malformation percutaneous treatment
Of note, VIR does not place PICC lines (contact PICC team), and generally does not place or pull inpatient non-tunneled central lines (contact medical procedure team).
Body Procedures
CONTACT & HOURS: Mon-Fri 7:30 am to 5:00 pm 206-3465 (Body IR pager). If emergent procedure is required between 5:00 pm and 10:00 pm Monday-Friday, or 7:30 am to 12:00 pm on weekends/holidays, please call the Body reading room (684-7224). If emergent intervention is required overnight, please call the Radiology Senior Call phone (681-4422).
PROCEDURES:
- Intraabdominal and superficial soft tissue drain placement and aspiration (U/S and CT-guided)
- Percutaneous solid organ and other intraabdominal biopsies, both targeted and random (U/S and CT-guided)
- Lumbar level paravertebral abscesses drainage
- See 'GI / GU Fluoroscopy' for information on Dobhoff tubes, esophograms, upper GI exams, contrast enemas, etc
GI / GU Fluoro Studies
CONTACT & HOURS: Monday-Friday 7:30am-5:00pm 684-7257; urgent procedures 7:30am - 12:00 pm on the weekend 684-7224 (body reading room); emergent procedure after 5pm Monday-Friday 681-4475 (Jr Call phone)
PROCEDURES:
- Imaging-guided Dobhoff tube placements (after failed attempt on floor)
- Esophagrams, Upper GI studies (evaluate through the ligament of Trietz), and small bowel follow throughs (for intestinal motility)
- Contrast enemas (water-soluble contrast for leaks, barium for pre G-tube placement)
- Fluoroscopic cystograms and retrograde urethragrams (RUGs)
- For similar exams but in the pediatric patients, please see 'Pediatric Fluoroscopic Studies' for more information
Pediatric Fluoro Studies
CONTACT & HOURS: 684-7288 7:30 am to 5:00 pm Mon-Fri and 7:30 am to 12:00 pm on the weekend. Emergent after hours studies available by calling Radiology Junior Call phone (681-4475)
PROCEDURES:
- Fluorscopic upper GI exams (evaluate for malrotation, upper GI pathology) and contrasted enemas
- Fluoroscopic Dobhoff tube placement
- Fluoroscopic percutaneous GTube / GJ tube checks
- Intussusception reductions
Neuroradiology Interventions
CONTACT & HOURS: For fluoroscopic guided LPs after failed bedside attempt, Mon-Fri 7:30am-5pm pager 206-9959. For all other procedures and for urgent procedures between 5:00 pm and 10:00 pm Monday-Friday, or 7:30 am - 12:00 pm on the weekend, call 684-7213 (neuro reading room). If emergent intervention is needed overnight, please call 681-4422 (Sr call phone).
PROCEDURES:
- Fluoroscopic guided lumbar punctures (following failed bedside LP attempt) - pager 206-9959 during business hours
- Myelograms
- For CSF-leak related interventions, please call the neuroradiology reading room at 684-7213.
- For vertebral body / disc aspiration, please call the neuroradiology reading room at 684-7213.
- For paravertebral abscess drainage, contact the Thoracic Interventions(see below) for thoracic level abscesses and Body Procedures (see above) for lumbar level disease.
Neurovascular Interventional Radiology
Neurovascular IR is staffed by neurosurgery, and can be reached at the functional pager 970-2671. Neurovascular interventions include:
- Intracranial vasculature occlusion suction thrombectomy
- Intracranial aneurysm embolization
Musculoskeletal Interventions
CONTACT & HOURS: Routinely available from 7:30 am to 5:00 pm Mond-Fri by calling the MSK reading room (684-7247). If emergent intervention is required between 5:00 pm and 7:30 am or on the weekend, please call the Radiology Senior Call phone (681-4422).
PROCEDURES:
- Fluoroscopy guided bone biopsies, marrow aspiration
- Shoulder and hip arthrograms and aspirations
Thoracic Interventions
CONTACT & HOURS Routinely available 7:30 am to 5:00 pm Mon-Fri by calling the CTI reading room (684-7419). If emergent intervention is required outside of these hours, please call the Radiology Senior Call phone (681-4422).
PROCEDURES:
- Lung / mediastinal / pleural biopsy not accessible by interventional pulmonology
- CT guided thoracentesis / chest tube placement if not successful by ultrasound approach with interventional pulmonology
- Thoracic level paravertebral abscesses drainage
