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Radiology Basics

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Procedure Preparation

  1. What are the guidelines for radiologists to plan and perform a procedure?
  2. What are the steps involved in pre-procedure preparation for interventional radiology?
  3. What are the post-procedure considerations for interventional radiology?
  4. What are the special considerations for certain patient populations in interventional radiology?

Requesting procedures

The Royal College of Radiologists has comprehensive and clear guidelines used nationally in the UK called iRefer. This sets out the minimum requirements for imaging and procedure requests from clinicians to radiologists in the UK. The guidelines outline the necessary information that should be included in a request, such as the patient’s clinical history, relevant examination findings, and the specific reason for the procedure.

This ensures that the radiologist has all the necessary information to plan and perform the procedure effectively. It stipulates every request must include the requesting clinician’s contact name and contact number (not just their bleep!) so they can be easily reached for further discussion if required.

At this stage, the requesting clinical team should also think about preparing the patient for the procedure. If it is vetted expediently by the radiologist, the patient will require pre-procedure blood tests and pre-consent, usually taken by the requesting team.

Patient preparation

Prior to the procedure, the patient may be required to fast for a certain period of time, depending on the nature of the procedure and the area being examined.

In some cases, the patient may need to stop taking certain medications (commonly anticoagulants or diabetes medications) prior to the procedure, as instructed by their operator.

The patient may also be required to remove any metallic objects, such as jewellery or glasses, that could interfere with the imaging or procedure.

Prior to requesting a procedure, the patient’s medical history, clinical presentation, and imaging results should be reviewed. The interventional radiologist should determine the appropriate procedure based on the patient’s condition and the potential risks and benefits.

The procedure should be explained to the patient, including the purpose, steps involved, potential complications, and expected outcomes.

Written informed consent should be obtained from the patient or their legal representative, or ‘consent form 4’ will be done if the patient lacks mental capacity. If this is the case, the procedure plan should always be discussed prior with the next of kin to inform them and answer any questions they may have.

Any necessary pre-procedure preparations, such as fasting or discontinuing certain medications, should be communicated to the patient and requesting team. Any important pre-procedure blood test and investigations should be done by the clinical team well before the procedure, specifically clotting, international normalised ratio (INR), prothrombin time, full blood count, urea, electrolytes and creatinine along with group and save (blood type so the lab can swiftly match blood products if there is sufficient blood loss).

If necessary, arrangements should be made for sedation or anaesthesia during the procedure. This may require review by a consultant anaesthetist too.

If contrast will be used in the procedure intravenously, it is important to check the renal function in terms of eGFR and creatinine level. If these are abnormal your local guidelines may suggest giving IV fluids before the procedure to reduce possible harm to the kidneys.

The interventional radiology team should ensure that all necessary equipment and supplies are available and sterile.

Informed consent

Documented formal consent should be obtained by the interventional radiologist from the patient or their legal representative before proceeding with the procedure. This is a really important step and cannot be understated, particularly for interventional radiologists, as this is often the first time they will meet the patient. Most procedures IRs perform are requested by another specialty caring for the patient. This is the best chance for the IR to check whether they agree with the procedure request by taking a thorough, directed history and elucidating if the procedure is actually indicated and in the best interests for the patient at that time.

Taking consent involves explaining the risks, benefits, and potential alternatives to the patient in a clear and understandable manner. The patient should have an opportunity to ask questions and have any concerns addressed. If the patient lacks the mental capacity to provide informed consent, the next of kin should be involved in the discussion and decision-making process. Documentation of the informed consent process should be thorough and include the patient’s understanding, agreement, and any additional information provided. The interventional radiology team should ensure that all necessary steps are taken to ensure patient safety and comfort throughout the procedure.

Risk of bleeding

An assessment regarding the patient’s risk of bleeding should be undertaken prior to intervention. Consideration should be given to the risk of bleeding from the procedure and patient risk factors, including any history of severe bleeding and any medications the patient is taking. Anticoagulant medications may need temporarily stopping prior to intervention. The BSIR has published IR bleeding risk guidance jointly produced by the BSIR Safety & Quality Committee in conjunction with the British Society of Haematology.

Prophylactic antibiotics

Prophylactic antibiotics may be given to prevent infection during or after the procedure.

Conscious sedation

Conscious sedation may be used to keep the patient relaxed and comfortable, for example drugs like midazolam may be given.

Local anaesthetic agents

Local anaesthetic agents, such as lidocaine, are used to numb the area where the procedure will be performed.

World Health Organisation (WHO) Surgical Safety Checklist for Radiological Intervention

This checklist was produced in 2010 after collaboration between the Royal College of Radiologists (RCR) and National Patient Safety Agency (NPSA).

Cardiovascular and Interventional Radiological Society of Europe (CIRSE) have also produced an IR Patient Safety Checklist.

We will focus on the former, which is used in the NHS.

It comprises 3 sections which are all to be read out loud:

Sign In

This phase is conducted before giving any anaesthesia (local or general) at the start of the radiological procedure.
  1. Team introduction
    • All team members, including the radiologist, anaesthetist, nurses, radiographers and any observers introduce themselves and their roles.
  2. Patient identification
    • Verify the patient’s identity using name and date of birth and match them to the procedure details.
  3. Procedure confirmation
    • Confirm the details of the radiological intervention, including the type of procedure, the area of focus, and any special requirements or considerations.
  4. Allergies and medical history
    • Discuss any known allergies or relevant medical history that could impact the procedure or patient safety. This will commonly involve checking blood results for clotting and renal function.
  5. Consent confirmation
    • Ensure that the patient’s informed consent for the radiological intervention has been obtained.

Time Out

This phase takes place just before the skin incision (or the start of the radiological intervention) and involves key checks to prevent errors.

  1. Procedure verification
    • Reconfirm the details of the procedure, the intended site of intervention, and any specific requirements or equipment needed.
  2. Anesthesia check
    • If applicable, ensure that the anaesthesic team is ready and aware of any specific anaesthesia requirements for the procedure.
  3. Radiation safety
    • Discuss radiation safety measures, including the use of protective equipment for both patients and staff, and the strategy for minimising radiation exposure.
  4. Anticipated challenges
    • Identify any potential challenges or critical steps in the procedure and discuss strategies to address them.

Sign Out

This phase occurs before the patient leaves the radiology suite or operating room and focuses on final checks and communication:
  1. Procedure completion
    • Confirm that the radiological intervention has been successfully completed, and there are no outstanding tasks.
  2. Instrument and equipment count
    • Verify that all instruments, tools, and equipment used during the procedure have been accounted for and are not left inside the patient.
  3. Radiation exposure review
    • Discuss the estimated radiation dose delivered to the patient and any necessary follow-up steps related to radiation exposure.
  4. Critical findings
    • Review any unexpected or critical findings that were discovered during the procedure and discuss the appropriate follow-up actions.
  5. Patient handoff
    • Communicate important post-procedure information to the relevant healthcare professionals who will be responsible for the patient’s ongoing care. By implementing these adapted steps from the WHO Surgical Safety Checklist, radiology teams can enhance communication, prevent errors, and prioritise patient safety during radiological interventions. In a later section we will cover what post-procedure involves; monitoring, discharge instructions, follow-up appointments and complication management.

Special considerations

When preparing for procedures in IR, it is important to take into account the specific needs of different patient populations. The following are some special considerations for paediatric, elderly, disabled, pregnant, and patients with renal dysfunction.

Paediatric patients

Ensure a child-friendly environment to reduce anxiety. Use appropriate paediatric-sized equipment. Employ play specialists or distraction techniques before and during the procedure. Minimise radiation exposure by using image guidance techniques with lower doses.

Elderly patients

Be aware of any comorbidities and frailty. Ensure proper monitoring of vital signs and hydration status. Provide additional assistance with mobility and positioning.

Disabled patients

Ensure accessibility to the procedure room and equipment. Communicate effectively with patients who have communication challenges. Consider the use of assistive devices or support personnel as needed.

Pregnant patients

Assess the risks and benefits of the radiological intervention for both the mother and the foetus. Utilise appropriate shielding techniques to minimise radiation exposure to the feotus. Obtain informed consent and ensure the patient is aware of any potential risks.

Patients with renal dysfunction

Monitor renal function and adjust contrast agent usage accordingly. Consider alternative contrast agents or imaging modalities that are less nephrotoxic. Communicate with the renal team to ensure proper management of renal function if severe. Monitor for signs of contrast-induced nephropathy and take appropriate measures to prevent or manage it.

Bites

  • The Royal College of Radiologists has clear guidelines called iRefer that outlines the information necessary from referrals for radiologists to plan and perform a procedure.
  • Pre-procedure preparation involves checking clotting parameters, administering prophylactic antibiotics, using conscious sedation, using local anaesthetic agents, radiation protection and addressing the patient’s understanding and consent.
  • The WHO checklist is an essential part of any procedure.
  • Special considerations for paediatric, elderly disabled, pregnant, and renal dysfunction patients.
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