BALLARAT HEALTH SERVICES BASE HOSPITAL Radiology Department Information Procedures and Preparations This document is intended as a resource for nursing and medical staff. It describes preprocedure requirements and post procedure care. Please note that indications are a guideline only and although it lists most of the procedures performed in the department it is not an exclusive list. For any other procedures or enquires please contact the department for further information. Reviewed JANUARY 2010 Table of Contents About The Radiology Department ............................................................. 5 Hours of Service .......................................................................... Radiology Department Contact Details ...................................................... Services Provided ......................................................................... Booking Requirements ...................................................................... Availability of Results ................................................................... Contrast Media ............................................................................ 5 5 5 5 5 6 Contrast Media Protocols ................................................................... 6 Acute Renal failure Secondary to Contrast Media Nephrotoxicity ............................ Extravasation of Contrast Protocol ........................................................ Metformin and Contrast Media Protocol ..................................................... Premedication of patients with previous known Allergy to non-ionic Contrast Media ......... 6 6 6 6 Interventional Procedures and anti-coagulation ............................................. 6 CT Scanning ................................................................................ 7 CT Abdomen and Pelvis ..................................................................... 7 CT Chest Abdomen and Pelvis ............................................................... 7 CT IV Cholangiogram ....................................................................... 7 CT Upper Abdomen .......................................................................... 8 CT Renal - Abdomen for Renal Stones ....................................................... 8 CT Brain (Routine) ........................................................................ 8 CT Brain (6 Years and Under) .............................................................. 8 CT Facial Bones .......................................................................... 10 CT Internal Auditory Meati ............................................................... 10 CT Orbits ................................................................................ 10 CT Pituitary Fossa ....................................................................... 10 CT Sinuses ............................................................................... 10 CT Larynx ................................................................................ 11 CT Neck - Soft Tissue .................................................................... 11 CT Chest (Routine) ....................................................................... 11 CT Chest - High Resolution ............................................................... 11 CT Pelvis - Bony ......................................................................... 12 CT Pelvis - Soft Tissue .................................................................. 12 CT Pelvimetry ............................................................................ 12 CT - Cervical, Thoracic or Lumbar (Non Contrast) ......................................... 12 CT - Cervical, Thoracic or Lumbar with Myelography ....................................... 12 Discogram ................................................................................ 13 Facet Joint Injection .................................................................... 13 Limited Epidural Injections .............................................................. 13 CT Shoulder .............................................................................. 13 CT of Bony Extremities ................................................................... 14 CT Angiography ........................................................................... 14 CT Guided Biopsy ......................................................................... 14 CT Guided Drainage ....................................................................... 14 CT COLONOSCOPY ........................................................................... 15 CT CORONARY ANGIOGRAM .................................................................... 15 Radiological Procedures ................................................................... 16 IVC (Intravenous Cholangiogram) .......................................................... 16 Percutaneous Biliary Drainage and Stenting ............................................... 16 Page 2 of 53 2 Sialogram ................................................................................ Pericardial Tap .......................................................................... US Guided Thoracentesis - Pleural Tap .................................................... Liver Biopsy – Ultrasound Guided ........................................................ US Guided Ascites Tap - Abdominal Paracentesis ........................................... US Guided Breast Cyst Aspiration or Lesion Biopsy ........................................ US Guided Breast Hook Wire Localisation ................................................. US Guided Thyroid Cyst Aspiration or Lesion Biopsy ....................................... IVP (Intravenous Pyelogram) .............................................................. Micturating Cysto Urethrogram (MCU) ...................................................... Nephrostogram ............................................................................ Percutaneous Nephrostomy ................................................................. Ultrasound Hysteroinflation. ............................................................. HSG (Hystero-Salpingogram) ............................................................... Lumbar Puncture – Fluoroscopic Guidance ................................................. Medial Branch Nerve Ablation ............................................................. Myelogram - Cervical, Thoracic, Lumbar ................................................... Nerve Root Injection ..................................................................... Neural Ablation .......................................................................... Vertebroplasty ........................................................................... Hip Injection ............................................................................ Arthrogram ............................................................................... Armport Insertion ........................................................................ Angiography - DSA ........................................................................ IVC (Inferior Vena Cava) Filter .......................................................... Leg Segmental Pressure Studies ........................................................... Permacath Insertion ...................................................................... Permacath Check with/without Urokinase Lock .............................................. Peripheral Angioplasty or Stenting ....................................................... PICC (Peripherally Inserted Central venous Catheter) Line Insertion ...................... ERCP-Endoscopic retrograde cholangiopancreatography ...................................... Percutaneous Biliary Drainage and Stenting ............................................... Pericardial Tap .......................................................................... Sialogram ................................................................................ Sinugram ................................................................................. 16 17 17 17 18 18 18 19 19 19 19 21 21 21 21 22 22 24 24 24 25 25 25 25 26 26 26 27 27 27 28 28 28 29 29 Fluoroscopic procedures ................................................................... 30 Barium Enema (air or double contrast) .................................................... Barium Follow Thorough ................................................................... Barium Meal .............................................................................. Naso-Jejunal Tube Insertion .............................................................. Barium Swallow ........................................................................... Video Fluoroscopy ........................................................................ 30 30 30 30 30 31 Ultrasound Scanning ....................................................................... 32 Neonate Abdominal Ultrasound ............................................................. Upper Abdominal Ultrasound ............................................................... Upper Abdomen and Pelvic Ultrasounds ..................................................... Bladder Ultrasound - Pre and Post Micturition ............................................ Prostatic Coil / Memokath Ultrasound ..................................................... Renal Ultrasound ......................................................................... Pelvic Ultrasound ........................................................................ Pelvic TV (Trans-vaginal) Ultrasound ..................................................... 32 32 32 32 33 33 33 33 Transvaginal Ultrasound Information ....................................................... 34 Obstetric Ultrasound – less than 15 weeks gestation. .................................... 34 Obstetric Ultrasound - after 15 weeks gestation. ......................................... 35 Obstetric Ultrasound – 12 week / Nuchal Translucency ................................... 35 Page 3 of 53 3 Ultrasound of Small Parts ................................................................ Arterial Leg Doppler ..................................................................... A/V Fistulogram .......................................................................... Aorta or IVC (Inferior Vena Cava) Ultrasound ............................................. Doppler Abdomen .......................................................................... Doppler Renal ............................................................................ DVT Ultrasound - Leg Veins Doppler ....................................................... Echocardiogram ........................................................................... Varicose Veins Ultrasound - Doppler ...................................................... Liver Biopsy – Ultrasound Guided ........................................................ US Guided Ascitic Tap - Abdominal Paracentesis ........................................... US Guided Breast Cyst Aspiration or Lesion Biopsy ........................................ US Guided Breast Cyst Aspiration or Lesion Biopsy ........................................ US Guided Breast Hook Wire Localisation ................................................. US Guided Thoracentesis - Pleural Tap .................................................... US Guided Thyroid Cyst Aspiration or Lesion Biopsy ....................................... 35 36 36 36 37 37 37 37 38 38 38 39 39 39 39 40 MRI Scanning .............................................................................. 40 You must have a specialist provider number to order these scans. .......................... 40 What is MRI .............................................................................. Preparing for the Test ................................................................... Information on and Preparation for Sedation .............................................. What Happens During the Scan ............................................................. After the Test ........................................................................... 40 40 41 41 42 Mammography ............................................................................... 43 Needle localisation of Breast Lesion ..................................................... 43 Restricted Medication ..................................................................... 44 Appendix (Contrast Protocols Ballarat Health Services)………………………………………………….46-54 Page 4 of 53 4 About The Radiology Department Hours of Service Monday to Friday (excluding Public Holidays) Saturday, Sunday and Public holidays - 8am to 6pm - 9am to 12noon A twenty-four hour EMERGENCY Radiology service is available. Patients must attend via the Emergency Department for their safety and to coordinate with the hospital’s needs. After 6pm weekdays or after 12noon on weekends and public holidays all services must be arranged via the Emergency Department. To arrange this service contact the Emergency Department on 03 5320 4000. An emergency service only is available on Christmas Day. Radiology Department Contact Details Our direct numbers are: Our Fax number is: Our e-mail address is: 03 5320 4270 or 5320 4271. 03 5340 4830 radiology@bhs.org.au Services Provided Angiography Ultrasound CT MRI Fluoroscopy OPG and General X-ray. Booking Requirements All CT scans, Ultrasounds or procedures requiring preparation or contrast require an appointment. Contact the department on 03 5320 4270 or 5320 4271 or the patient may book in person at the department. All general x-rays do not require an appointment and can be undertaken any time during the office hours above. In-patients require an appointment time for the orderlies to collect them from the ward area. Children may require special preparation for procedures not listed in this book, please contact the department for this information. Please ensure that the department is made aware of any patient who has diabetes and is required to fast for a procedure. Meals and administering of insulin can be arranged. If the patient is on Metformin please read the section on Contrast Media. Any further information or specific enquires please contact the department. Availability of Results We endeavour to have results available within 24-48 hours of the examination. Results should be available on the hospital computer system prior to this. An ‘Unverified result’ means that the radiologists have not yet validated the report. Page 5 of 53 5 Urgent results are available via phone or fax. Please state clearly on the request form if urgent notification of results is required. Images and results are available electronically via the BHS intranet. Contrast Media All intra-vascular contrast media used is iodine based. If your patient has a previous known reaction, please contact the department to discuss appropriate pre-medication to ensure that the procedure is completed safely and without delay. If your patient is on Metformin please ensure a recent renal function test is available. Metformin is excreted via the same pathway as contrast media and it is recommended that Metformin is ceased for 48 hours following contrast media injection. Preparation, prior to contrast media injection, may be required for patients with abnormal renal function. If your patient has a Estimated Glomerular Filtration Rate below 50mls/hr please follow the Radiology Department protocol for abnormal renal function or contact the department for further information. Iodinated contrast media is nephrotoxic and excreted unchanged via the kidneys. Contrast Media Protocols (see appendix) Acute Renal failure Secondary to Contrast Media Nephrotoxicity p.46 Extravasation of Contrast Protocol p.52 Metformin and Contrast Media Protocol p.48 Premedication of patients with previous known Allergy to non-ionic Contrast Media p.50 Interventional Procedures and anti-coagulation Some interventional procedures require clotting times to be done prior to the procedure. Ceasing anticoagulants prior to an interventional procedure should only be done at the discretion of the treating medical officer. General Guidelines: Please contact the department with any queries. Warfarin should be ceased 4-5 days prior to procedure. Depending on indication for warfarin, patients may or may not need to be heparinised. IV Heparin should then be ceased 4 hours prior to the procedure. Therapeutic doses of Clexane should be ceased 24 hours prior to a procedure. Sub-therapeutic doses of clexane should be ceased 12 hours prior to a procedure. Clopidogril should be ceased 10 days prior to a procedure in most patients depending on indication. Aspirin should be withheld on the day of the procedure Page 6 of 53 6 CT Scanning Multi-slice 3 dimensional scanning is performed at Ballarat Health services. This allows for the isotropic reconstruction of the images in coronal, sagittal and the standard axial planes. This allows for more accurate interpretation of the CT images. Bookings are required for CT Studies, though exceptions are made for urgent requests. CT Abdomen and Pelvis Possible indications include: Trauma, abdominal pain, appendicitis, tumour evolution/oncology. Preparation: Routine 4 hour fast. 1 hour prior to examination the patient must start drinking the dilute Gastrografin or barium preparation. The drinking of the contrast fluid is undertaken in the department to ensure that an appropriate quantity is taken over an appropriate period of time. The patient is then asked to change and given the opportunity to go to the toilet prior to the procedure. Post procedure care: If IV contrast is given encourage oral fluids. CT Chest Abdomen and Pelvis Possible indications include: Trauma, appendicitis/generalised abdominal pain, lymphoma, lymph node enlargement, staging mass, hernia evaluation. Preparation: Routine 4 hour fast. 1 hour prior to examination the patient must start drinking the dilute gastrografin or barium preparation. The drinking of the contrast fluid is undertaken in the department to ensure that an appropriate quantity is taken over an appropriate period of time. The patient is then asked to change and given the opportunity to go to the toilet prior to the procedure. Post procedure care: If IV contrast is given encourage oral fluids. CT IV Cholangiogram Possible indications include: Visualisation of the Common Bile Duct, e.g. post cholecystectomy with continuing pain. This is undertaken in conjunction with a standard IV Cholangiogram. Abnormal liver function tests may affect the absorption of the contrast media. Preparation: Low residue diet the day prior to the procedure and a laxative in the evening following the evening meal. Nothing further to eat after this time. Drinking clear fluids is important, as dehydration is a contraindication to the procedure. Post procedure care: Encourage fluids. Page 7 of 53 7 CT Upper Abdomen Possible indications include: Upper abdominal pain, liver lesions. Preparation: Routine 4 hour fast. 1 hour prior to examination the patient must start drinking the dilute Gastrografin or barium preparation. The drinking of the contrast fluid is undertaken in the department to ensure that an appropriate quantity is taken over an appropriate period of time. The patient is then asked to change and given the opportunity to go to the toilet prior to the procedure. If the patient is having a scan to follow up on a known liver lesion, oral contrast is not required and the patient attends the department 15 minutes prior to the examination. Post procedure care: If IV contrast is given encourage oral fluids. CT Renal - Abdomen for Renal Stones Possible indications include: Renal colic, haematuria Preparation: Full bladder required. IV and oral contrast are not required. Post procedure care: None. CT Brain (Routine) Possible indications include: Trauma, CVA, infarct, hydrocephalus, headaches, seizures, possible pathology. Preparation: Routine 4 hour fast. Post procedure care: If contrast is given, encourage oral fluids. CT Brain (Infant or child) Possible indications include: Trauma ,possible pathology Preparation: Many children need sedation or a general anaesthetic for CT scans. The child will need to be admitted to the hospital for the day. If required, anaesthetic care will need to be organised. FASTING: If the child’s procedure is in the morning they must not eat solid food or drink milk after 4am and must have nothing else to drink after 6am. For an afternoon procedure, the child must not eat solid food or drink milk after 9 am and they must not drink anything after 11am. Between 9am and 11am small amounts of water or juice may be taken. Breastfeeding must cease 4 hours prior to the scan. Page 8 of 53 8 A CONSENT FORM is required. Post procedure care: As requested by Anaesthetist Page 9 of 53 9 CT Facial Bones Possible indications include: Trauma Preparation: Nil required. Post procedure care: None. CT Internal Auditory Meati Possible indications include: Vertigo, suspected acoustic neuroma. Preparation: Routine 4 hour fast. Post procedure care: If contrast is given, encourage oral fluids. CT Orbits Possible indications include: Visual disorders, proptosis, foreign bodies, trauma. Preparation: Routine 4 hour fast. Post procedure care: If contrast is given, encourage oral fluids. CT Pituitary Fossa Possible indications include: Hormonal disorders, visual disturbances. Preparation: Routine 4 hour fast. Post procedure care: If contrast is given, encourage oral fluids. CT Sinuses Possible indications include: Chronic sinusitis, polyps, trauma, bone destruction. Preparation: Nil required. Post procedure care: None. Page 10 of 53 10 CT Larynx Possible indications include: Vocal chord abnormality, as directed by the radiologist. Preparation: Routine 4 hour fast. Post procedure care: If contrast is given, encourage oral fluids. CT Neck - Soft Tissue Possible indications include: Palpable neck mass. Preparation: Routine 4 hour fast. Post procedure care: If contrast is given, encourage oral fluids. CT Chest (Routine) Possible indications include: Lung Disease. Preparation: Routine 4 hour fast. Post procedure care: If contrast is given, encourage oral fluids. CT Chest - Aortic Dissection Possible indications include: Dissecting aneurysm. Preparation: Routine 4 hour fast if the patient’s condition permits. Post procedure care: Encourage fluids if the patient’s condition permits. CT Chest - High Resolution Possible indications include: Diffuse lung disease. Preparation: No fast required. normal. If the patient takes regular broncho-dilators these should be taken as Post procedure care: Page 11 of 53 11 None. CT Pelvis - Bony Possible indications include: Fractured pelvis or hips, pathology Preparation: None required. Post procedure care: None. CT Pelvis - Soft Tissue Possible indications include: Pelvic pathology Preparation: Routine 4 hour fast. 1 and a ½ hours prior to examination the patient must start drinking the dilute gastrografin or barium preparation. The drinking of the contrast fluid is undertaken in the department to ensure that an appropriate quantity is taken over an appropriate period of time. The patient is then asked to change and given the opportunity to go to the toilet prior to the procedure. Post procedure care: If IV contrast is given encourage oral fluids. CT Pelvimetry Possible indications include: Post Partum evaluation. Preparation: None required. Post procedure care: None. CT - Cervical, Thoracic or Lumbar (Non Contrast) Possible indications include: Trauma, neural deficit, back pain/ sciatica. Preparation: None required Post procedure care: None. CT - Cervical, Thoracic or Lumbar with Myelography Possible indications include: Page 12 of 53 12 Back pain, disc lesion, canal stenosis, neural loss, previous surgery or previous scan without contrast where further information may be gained with Myelography. An MRI scan may be the procedure of first choice. Preparation: See Myelography. Discogram Possible indications include: Evaluation of the structure and functional integrity of the nucleus/annulous. useful in assessing the severity of disc herniation or degeneration. Especially Preparation: Light diet for the meal prior to the examination. patient home following the procedure. An escort is required to drive the Post procedure care: The patient meeds to rest for 24 hours post procedure, standing as much as possible in the first 12 hours. Standing aids the reabsorption of the fluids injected into the disc. Facet Joint Injection Possible indications include: To determine if a facet joint is causative in patients’ back or leg pain. Preparation: Light diet for the meal prior to the examination. patient home following the procedure. An escort is required to drive the Post procedure care: Return to usual activities. Limited Epidural Injections Possible indications include: Therapeutic procedure for symptomatic central disc herniation or degeneration. Preparation: Light diet for the meal prior to the examination. patient home following the procedure. An escort is required to drive the Post procedure care: As for a myelogram. CT Shoulder Possible indications include: Recurrent dislocations, rotator cuff injuries, tendon tears, fractures, bony abnormality Preparation: If for bony examination, no preparation is required. If soft tissues are to be studied the patient should have a shoulder arthrogram prior to CT. Post procedure care: None. Page 13 of 53 13 CT of Bony Extremities Possible indications include: Trauma/pathology. Preparation: None required. Post procedure care: None. CT Angiography Possible indications include: Pathology of major arteries - pulmonary, carotid, renal and intra-cranial and aorta. Preparation: 4 hour fast. Post procedure care: Encourage fluids. CT Guided Biopsy Possible indications include: Known lesion visible and accessible under CT for pathology assessment. Preparation: Routine 6 hour fast. The region should have had previous imaging and these films and reports must be available. Patient may be booked into the hospital at the discretion of the requesting medical practitioner. Some biopsies may be appropriate to be performed on an outpatient basis. The patient must be aware of the risk of having to stay in hospital overnight and resting for the remainder of the day if they return home. Clotting times are required for all biopsies and should be done the day before. Post procedure care: In-patients are returned to the ward with a post biopsy care sheet. If the procedure is being performed on an outpatient basis the patient is kept in the department resting and monitored for at least an hour prior to being released into the care of another person. Lunch or a drink will be provided. CT Guided Drainage Possible indications include: Drainage of an abscess or fluid filled structure requiring CT guidance. therapeutic, diagnostic or both. This may be Preparation: Routine 6 hour fast. The region should have been previously imaged and these films and reports must be available. Page 14 of 53 14 Patient may be booked into the hospital at the discretion of the requesting medical practitioner. Some drainages may be appropriate to be performed on an outpatient basis. The patient must be aware of the risk of having to stay in hospital overnight and resting for the remainder of the day if they return home. Clotting times are required for all drainages and should be done the day prior. Post procedure care: In-patients are returned to the ward with a post drainage care sheet. left insitu. A drain tube may be If the procedure is being performed on an outpatient basis the patient is kept in the department resting and being monitored for at least an hour prior to being released into the care of another person. Lunch or a drink will be provided. CT FISTULOGRAM No preparation .Needs to be booked by nurses. CT COLONOSCOPY Possible indications include: Diagnostic test for polyps and other lesions in the bowel. It is a minimally invasive procedure using air and is a good alternative for patients at risk of complications due to anaesthetic. Preparation: Needs to be booked by a nurse. Need Picolax preparation as for colonoscopy. Post procedure: Can return to normal activities after procedure. May have some abdominal discomfort. CT CORONARY ANGIOGRAM Needs to be booked by a nurse. Preparation: 4 hour fast. need to come an hour early. May need a betablocker to slow the heart rate. Post procedure care: Need someone to drive them home. Page 15 of 53 15 Radiological Procedures Routine non-contrast examinations do not require appointments or preparation. In-patients require an appointment time for the orderlies to arrange collect the patient from the ward area. All interventional procedures require an appointment. IVC (Intravenous Cholangiogram) Possible indications include: When visualisation of the Common Bile Duct is required, e.g. post cholecystectomy with continuing pain. This is undertaken in conjunction with a CT reconstruction. Preparation: Low residue diet the day prior to the procedure. Nothing further to eat after this time. Drinking clear fluids is important, as dehydration is a contraindication to the procedure. Post procedure care: Encourage fluids. Percutaneous Biliary Drainage and Stenting Possible indications include: Failure of stenting at ERCP with a sound therapeutic reason to undertake this procedure due to the morbidity and mortality associated with Percutaneous Biliary Drainage. Preparation: Routine 6 hour fast. Recent CT scan of the liver showing the dilated biliary tree and any other liver pathology. Patient must be an in-patient. The patient must be aware of the risks involved and a consent form must be signed. An anaesthetist should be arranged. Clotting times and IV antibiotics are required prior to the procedure. The initial stage is to drain the biliary system only. If the lesion is crossed, an internal/external drain tube will be positioned. This may not be possible. Seven to ten days later the second stage of the procedure may be performed. the lesion is crossed or a permanent internal stent is positioned. This is where This may take up to three visits to complete. Post procedure care: The drain tube needs to be checked and the volume of bile draining measured. If the drain tube falls out the Radiology Department needs to be contacted urgently to attempt to reinsert the tube before the tract closes. If the drainage tract is not well developed replacement would have to wait until the biliary tree was again dilated. Sialogram Possible indications include: Pain and swelling in salivary glands or ducts Preparation: None required. This procedure may be undertaken in conjunction with an ultrasound or CT. Post procedure care: None. Page 16 of 53 16 Pericardial Tap Possible indications include: Cardiac tamponade. Preparation: This may be undertaken under either CT or ultrasound and needs to be discussed with the Radiologist on duty. It may be performed in ITU if necessary. Echocardiogram is essential. Fasting and clotting profile are preferable if time permits. There must be a nurse or doctor available to monitor the patient during this procedure as well as the nurse to assist the Radiologist. Post procedure care: Continue close monitoring, as prior to the procedure. insitu, to maintain drainage. Care of the drain tube, if it is left US Guided Thoracentesis - Pleural Tap Possible indications include: Pathology, symptomatic relief. Preparation: Four hour fast. Patient may be booked into the hospital at the discretion of the requesting medical practitioner. It may be performed on an outpatient basis. The patient must be aware of the possibility of having to stay in hospital overnight and needing to rest for the remainder of the day if they return home. Clotting times are required. Post procedure care: Chest x-ray, See Nursing Service Clinical Practice Guidelines. If the procedure is being performed on an outpatient basis, the patient is kept in the department resting for approximately an hour prior to being released into the care of another person. Lunch or a drink will be provided. Liver Biopsy – Ultrasound Guided Possible indications include: Pathological review of liver structure. Preparation: Four hour fast. Patient is booked as a day procedure. Clotting times are required. If there is any risk of an abnormal clotting profile this should be checked prior to the biopsy being performed. Post procedure care: Patient returns to the ward with a post care instructions. hour stay following the procedure. Page 17 of 53 There is a minimum of a four (4) 17 US Guided Ascites Tap - Abdominal Paracentesis Possible indications include: Pathology, symptomatic relief. Preparation: Four hour fast. Patient may be booked into the hospital at the discretion of the requesting medical practitioner. This is often performed on an outpatient basis. The patient must be aware of the need to rest for the remainder of the day if they are returning home. If there is any risk of an abnormal clotting profile this should be checked prior. Post procedure care: See Nursing Service Clinical Practice Guidelines. albumin replacement should be arranged. If ongoing drainage has been requested If the procedure is being performed on an outpatient basis the patient is kept in the department resting for approximately an hour prior to being released into the care of another person. Lunch or a drink will be provided. US Guided Breast Cyst Aspiration or Lesion Biopsy Possible indications include: Pathology. Pain relief. Preparation: Previous breast ultrasound / mammograms and reports must be available. Four hour fast. An US Guided breast Biopsy is performed as an Outpatient. Post procedure care: Family member / friend to drive patient home if required. bruising. Ice may be applied to decrease US Guided Breast Hook Wire Localisation Possible indications include: Breast mass. Preparation: Patient must be an inpatient and due for theatre that day if a Hook Wire Localisation is being performed. Previous breast ultrasound, with or without a mammogram must have been undertaken. The previous films and reports must be available. The lesion must be clearly visible under ultrasound. The patient will leave the radiology department with the hook wire insitu. Post procedure care: Continue preparation for theatre. Page 18 of 53 18 US Guided Thyroid Cyst Aspiration or Lesion Biopsy Possible indications include: Thyroid mass Preparation: Four hour fast. Previous thyroid ultrasound must be available. Clotting profile is required. Post procedure care: A post procedure instruction sheet will be given to the patient. Family member / friend to drive patient home if required. bruising. Ice may be applied to decrease IVP (Intravenous Pyelogram) Possible indications include: Renal colic (if CT scan is insufficient), haematuria, hypertension, suspected pathology. Not indicated for patients’ with renal failure. Preparation: Low residue diet the day prior to the procedure and a laxative is given following the evening meal. Nothing further to eat after this time. Nothing to drink for 12 hours prior to the examination. Post procedure care: Encourage fluids. Micturating Cysto Urethrogram (MCU) Possible indications include: Post renal tract infection, to check for ureteric reflux. Preparation: None Required. Any education the parent or carer can give the child about the procedure helps the child during the procedure. They can contact the department for specific information. The parent or carer may stay with the child during the procedure providing that they are not pregnant. Post procedure care: There is a risk of infection post MCU and the child should be observed for signs and symptoms of a UTI. A treat may be considered as a way of rewarding the child after the procedure. Nephrostogram Possible indications include: To check the patency of the ureter following stone extraction. Preparation: None required. Post procedure care: None. Page 19 of 53 19 Page 20 of 53 20 Percutaneous Nephrostomy Possible indications include: Ureteric blockage leading to a dilated collecting system, patient unsuitable for anaesthesia. Preparation: Consent form. IV access and IV antibiotics prior to arrival in the department. 4 hour fast. Anaesthetic assistance, for patient comfort, may be considered. Ultrasound may be considered. Post procedure care: Care of a drain tube or post care of a nephrostomy. Ultrasound Hysteroinflation. Possible indications include: Polyps, bleeding, fibroids, infertility. Preparation: Light diet prior. Drink 3 cups water 1 hour prior to arrival in department to fill bladder. Or as directed by the referring physician. Performed at any time whilst not menstruating. Post procedure care: Lower abdominal pain may be experienced post procedure, analgesic as required. A sanitary pad may be required after the procedure. An escort to drive the patient home may be appreciated. HSG (Hystero-Salpingogram) Possible indications include: Check of tubal patency, infertility. Preparation: Light diet prior, 2 Ponstan capsules an hour prior to the procedure. referring physician. Or as directed by the HSG must be undertaken following menstruation but before day 12-14 of the cycle. Post procedure care: Lower abdominal pain may be experienced post procedure, analgesic as required. A sanitary pad may be required after the procedure. An escort to drive the patient home may be appreciated. Lumbar Puncture – Fluoroscopic Guidance Indication: Where lumbar puncture has failed due to access, previous surgery or inability to find landmarks. Page 21 of 53 21 Preparation: See Nursing Services Clinical Practice Guidelines – Lumbar Puncture. Post procedure care: As indicated in Nursing Services Clinical Practice Guidelines. Medial Branch Nerve Ablation Possible indications include: Ablation of the medial branches of the posterior primary rami. This is undertaken in chronic low back pain where posterior element nociception is a key symptom. This is a procedure equivalent to chemical rhizolysis. Preparation: This procedure is always proceeded by a nerve block without ablation to ensure the relief of symptoms and assess the affected area. A four (4) hour fast is required. All previous imaging must be available. Good family support is required post procedure or hospital admission must be arranged prior. Post procedure care: Observation, in the Radiology Department, until symptoms are established. If there is good family support, discharge into their care with follow-up by the requesting medical practitioner. . Myelogram - Cervical, Thoracic, Lumbar Possible indications include: Back pain, neural deficit, usually performed in conjunction with a CT scan. MRI is the test of first choice. Preparation: 4 hour fast from food, however a litre of water must be drunk 1-2 hours prior to the procedure. A full bladder is not necessary, so they may go to the toilet as desired. consent form and hospital bed are required. A Medications which lower the seizure threshold must be avoided for 48 hours prior to the procedure (see the restricted medication list in the back of this book). Post procedure care: Drink plenty of water or cordial. Two cups per hour over the first two hours, then one cup per hour after this time is the minimum recommended. No alcohol. Ensure that the patient is aware that their head is not to be lower than their body at any time. This includes putting on shoes or picking up something. They stay in hospital overnight as minimal to no activity is recommended for 16 hours. must be aware that they will need to rest quietly in a sitting position. In bed it is recommended that they sleep on 2 - 3 pillows. They We recommend paracetamol (or their usual analgesic) for any headache that may occur following this procedure. Medication ceased prior to this procedure may be recommenced 24 hours after the procedure. A follow up CT of the area of interest can be performed 3-6 hours post myelogram. Page 22 of 53 22 Page 23 of 53 23 Nerve Root Injection Possible indications include: To determine if abolition of sensation in a nerve root abolishes a patient’s altered sensation (this may be due to disc herniation, spinal canal stenosis or nerve irritation). Perineural fibrosis. Preparation: Light diet for the meal prior to the examination. patient home following the procedure. An escort may be required to drive the Post procedure care: Diminished motor/sensory function in the nerve root will mean that the patient will require assistance for up to 8 hours. This can be undertaken on an outpatient basis. Neural Ablation Possible indications include: As a permanent form of pain relief where there is pathological involvement of a nerve root eg. Pancoast tumour in T1 or rarely an upper lumber tumour involving the extra foraminal nerve root in L1. Preparation: This procedure is always proceeded by a nerve block without ablation to ensure the relief of symptoms and assess the affected area. A four (4) hour fast is required. All previous imaging must be available. Good family support is required post procedure or hospital admission must be arranged prior. Post procedure care: Observation, in the Radiology Department, until symptoms are established. If there is good family support, discharge into their care with follow-up by the requesting medical practitioner. Vertebroplasty Possible indications include: Intractable pain due to crush fracture of a vertebral body, this may be secondary to osteoporosis or malignancy. Preparation: A 3D reconstructed CT scan of the affected area is required pre-procedure to determine access to the affected vertebral body. MRI scanning of the affected region is useful to determine the fractured vertebra is symptomatic. A pre-procedure consultation with the interventional radiologist may be required. Four (4) hour fast is required pre-procedure, as sedation will be given. The patient must be an admitted to the hospital. All previous films must accompany the patient. Post procedure care: Close observation for any motor/sensory function loss at the affected area. Pain relief as required. The patient may be able to ambulate, or stand out of bed, later in the day. Check the post procedure care notes. Page 24 of 53 24 Hip Injection Possible indications include: Temporary relief of hip pain. Preparation: Light diet for the meal prior to the examination. patient home following the procedure. An escort may be required to drive the Post procedure care: Temporary pain relief may be required after the effects of the long acting local anaesthetic have dissipated. The intra-capsular injection of steroid will become effective in 8-12 hours. Arthrogram Possible indications include: Pain, decreased mobility in a synovial joint. Preparation: Light diet for the meal prior to the examination. patient home following the procedure. An escort may be required to drive the Post procedure care: Oral pain relief may be required. The joint should be rested for 1-2 days as some increased joint pain and stiffness may be experienced for 24 hours or so. In knee arthrography there will be gas in the joint for 1-2 days. Armport Insertion Possible indications include: chemotherapy Preparation: Admission for a day case is required but patients can usually be discharged about 1 hour after the procedure. A 4 hour fast is required in case sedation needs to be given. Clotting times may be necessary. Check with Department. Upper arm veins are used. Post Procedure Care: Port may be accessed depending on patient’s requirements for chemotherapy. Intermittent icepacks are recommended for first few days to reduce swelling. The arm should be rested as much as possible. Needs to be checked for infection within 1 week of insertion for by LMO or Oncology clinic. Angiography - DSA Possible indications include: Arterial disease, ischaemia, graft evaluation, aneurysm, haemorrhage. Cardiac angiography is not undertaken at this hospital. Preparation: 4 hour food fast, continue to drink clear fluids before the procedure. well hydrated. Recent U&E’s and clotting profile are required. A day stay in hospital is required. The patient must be A consent form needs to be arranged. Page 25 of 53 25 Warfarin must be ceased and an INR needs to be performed the day prior to ensure that clotting time is satisfactory. Hospital admission and alternate therapy may be considered. Clopidogrel hydrogen sulfate (Plavix, Iscover) must be ceased 10 days prior to angiography depending on the indication. Contact the Radiology Department if in doubt. Post procedure care: The patient is kept in the department for 30-50 minutes after haemostasis has been obtained. After this time they are returned to their ward area and rest in bed for a further 3 ½ hours with frequent observations being performed. After this time (if there are no complications) the patient may be discharged. They require someone to drive them home and must rest for the remainder of the day. Care should be taken with heavy lifting, strenuous activity or driving for 48 hours following the procedure. IVC (Inferior Vena Cava) Filter Indication: Persistent pulmonary emboli, from a known venous lower limb focus, with inability to control the embolisation with medication. Prior to surgery, where there is a known risk of pulmonary infarction and a contraindication to anti-thrombolitic therapy. Preparation: Four (4) hour fast preferred. Clotting times appreciated but therapeutic times are not a contraindication to proceeding. Access can be achieved via a femoral or jugular vein, this may need to be discussed with the Radiologist prior to the procedure. A temporary IVC Filter is available with 24 hours notice in cases where filtration is required for a period of up to 10 days. Post procedure care: Frequent observation of the puncture site and resting in bed for two (2) hours following the procedure is required. If the site is satisfactory after this time normal activities may resume. If the procedure is a day case the patient will require someone to drive them home. Leg Segmental Pressure Studies Indication: Claudication. Preparation: None required. This procedure takes about an hour. Post procedure care: None. Permacath Insertion Indication: Renal Dialysis Preparation: Patients are admitted for a day case. Sedation is required so a 4 hour fast is necessary. Clotting times will need to be done. Post Procedure care: Patients are often transferred to the Dialysis Unit for Dialysis. Page 26 of 53 26 Permacath Check with/without Urokinase Lock Indication: Decreased flows noticed during haemodialysis. If a Urokinase lock is required this must be asked for specifically on the Radiology Request. Preparation: None required, if patient is known to tolerate contrast media. If a Urokinase lock is required then the procedure must take place approximately four (4) hours prior to haemodialysis. If this is not possible the patient must attend the dialysis unit to have the Urokinase withdrawn and a Heparin lock attended to. Post procedure care: Withdrawal of the Urokinase four (4) hours following the procedure. Peripheral Angioplasty or Stenting Possible indications include: Significant stenosis of a relatively short duration, or patient who is an unsuitable candidate for surgery with an amenable stenosis. Preparation: 4 hour fast. This requires an overnight stay in hospital. The procedure is generally undertaken in the afternoon. Recent U&E’s and clotting profile are required. Warfarin must be ceased and an INR needs to be performed the morning of or day prior to check the clotting time. Hospital admission and alternate therapy may be considered. Clopidogrel hydrogen sulfate (Plavix, Iscover) must be ceased 10 days prior to angiography. See product information for further details. Post procedure care: As for Angiography except the patient rests in bed until the following morning. PICC (Peripherally Inserted Central venous Catheter) Line Insertion Indication: For the intravenous administration of nutrient fluids, chemotheraputic agents, anti-biotics or other irritant drug therapies over a period of 4-12 weeks. The treating unit must organise the ongoing care of these lines for the patient when they are discharged from the hospital. Preparation: The Radiology Department utilises ultrasound guidance to access the large veins in the upper arm to decrease the risk of phlebitis or catheter fracture due to elbow movement. A section of upper arm must be available without any signs of infection and with a chance of some intact veins being present. A light diet prior is suggested and a clotting profile may be beneficial. However, therapeutic clotting times are not necessarily a contraindication to the insertion of a PICC line. This should be discussed with the Radiologist. Post procedure care: As indicated in Nursing Services Clinical Practice Guidelines. Page 27 of 53 27 ERCP-Endoscopic retrograde cholangiopancreatography Possible indications include: Diagnostic or therapeutic procedure outlining the bilary tree and allowing treatment of some conditions such as common bile duct stones and jaundice These conditions may require stone removal or stent insertion. It combines the use of endoscopy and fluoroscopy. Preparation: 6-8 hour fast, may need LFT’s and coags. A consent form is required. Check for allergies. Post procedure care: Routine post anaesthetic obs. IV fluids. Oral fluids only.diet next day . Pain relief. Usually overnight stay. Percutaneous Biliary Drainage and Stenting Possible indications include: Failure of stenting at ERCP with a sound therapeutic reason to undertake this procedure due to the morbidity and mortality associated with Percutaneous Biliary Drainage. Preparation: Routine 4 four fast. Recent CT scan of the liver showing the dilated biliary tree and any other liver pathology. Patient must be an in-patient. The patient must be aware of the risks involved and a consent form must be signed. An anaesthetist should be arranged. Clotting times and IV antibiotics are required prior to the procedure. The initial stage is to drain the biliary system only. If the lesion is crossed, an internal/external drain tube will be positioned. This may not be possible. Seven to ten days later the second stage of the procedure may be performed. the lesion is crossed or a permanent internal stent is positioned. This is where This may take up to three visits to complete. Post procedure care: The drain tube needs to be checked and the volume of bile draining measured. Close observation is required due to the risk of septic shock. If the drain tube falls out the Radiology Department needs to be contacted urgently to attempt to reinsert the tube before the tract closes. If the drainage tract is not well developed replacement would have to wait until the biliary tree was again dilated. Pericardial Tap Possible indications include: Cardiac tamponarde. Preparation: Page 28 of 53 28 This may be undertaken under either CT or ultrasound and needs to be discussed with the Radiologist on duty. It may be performed in ITU if necessary. Echocardiogram is essential. Fasting and clotting profile are preferable if time permits. There must be a nurse or doctor available to monitor the patient during this procedure as well as the nurse to assist the Radiologist. Post procedure care: Continue close monitoring, as prior to the procedure. to maintain drainage. Care of the drain tube, if it is left Sialogram Possible indications include: Pain and swelling in salivary glands or duct obstruction. Preparation: None required. This procedure may be undertaken in conjunction with an ultrasound or CT. Post procedure care: None. Sinugram Possible indications include: Investigation of a sinus or fistula. Preparation: Usually none or as required by the Radiologist. Post procedure care: None. Page 29 of 53 29 Fluoroscopic procedures Barium Enema (air or double contrast) Possible indications include: Change in bowel habits, bleeding, inflammatory bowel disease, pathology, failed colonoscopy. Preparation: Follow instructions on “X-Prep Kit” which begins 20 hours before the examination. X-Prep Kits may be obtained from the Radiology Department, kits can be supplied to general practices on request. Post procedure care: Encourage fluids and high fibre diet as constipation may occur. Barium Follow Thorough Possible indications include: Small bowel obstruction, inflammatory bowel disease. Preparation: 12 hour fast. Patient should be warned that the procedure may take a number of hours and a good book (walkman, or something to do lying down) is recommended. The delay is due to the wait for the barium to pass through the small bowel to the colon for the test to be completed. Post procedure care: Encourage fluids and high fibre diet as constipation may occur. Barium Meal Possible indications include: Dyspepsia, obstruction, suspected pathology. Preparation: Routine 12 hour fast Post procedure care: Encourage fluids and a high fibre diet as constipation may result. Naso-Jejunal Tube Insertion Indication: To rest the stomach while maintaining enteral feeding. Preparation: Four (4) hour fast is preferred but not essential. Post procedure care: Maintenance of the tube. Please ensure that the tube is flushed at least every four hours with warm water. Do not use soft drink or acidic fluids as this has been proven to coagulate the proteins and cause tube blocking. Do not remove a tube that has become blocked prior to talking to the radiology staff as we are sometimes able to unblock tubes with the assistance of fluoroscopy. Barium Swallow Possible indications include: Page 30 of 53 30 Dysphagia, oesophageal pathology. Preparation: 12 hour fast. Post procedure care: Encourage fluids and a high fibre diet as constipation may result. Video Fluoroscopy Possible indications include: Dysphagia, assessment following CVA. This procedure is booked via the Speech Pathology Department of the Base Hospital. information can be obtained from the speech pathologists. No fast is required. Page 31 of 53 Further 31 Ultrasound Scanning All Ultrasound (US) scans require an appointment within office hours. For emergency bookings within office hours (0830 – 1700) contact the Sonographers directly on Ext 94718. After hours scans / weekend scans need to be discussed with the On-call Radiologist who may be contacted through switchboard. Neonate Abdominal Ultrasound Possible indications include: Pyloric stenosis, abdominal mass. Preparation: Pyloric stenosis : Feed 20 mins prior to scan. Abdominal US : 2 hour fast. Post procedure care: None. Upper Abdominal Ultrasound Possible indications include: Upper abdominal pain, gallbladder pathology eg. cholelithiasis , cholecystitis, choledocholithiasis. pancreatitis, suspected pathology, hepato or spleno megaly, portal hypertension. Preparation: 12 hour fast. Post procedure care: None. Upper Abdomen and Pelvic Ultrasounds For outpatients these scans cannot be performed on the same day due to Medicare guidelines and the different preparations required. Bladder Ultrasound - Pre and Post Micturition Possible indications include: Frequency, retention, bladder pathology, prostate pathology. Preparation: A full bladder is required for this procedure. 4 glasses of water drunk over the two hours prior to the procedure is recommended. If a catheter is insitu within the bladder it should be clamped 2 hours prior to the appointment. Post procedure care: None. Page 32 of 53 32 Prostatic Coil / Memokath Ultrasound Possible indications include: Coil position, urinary retention, frequency. Preparation: A full bladder is required for this procedure. prior to the procedure is recommended. 4 glasses of water drunk over the two hours Post procedure care: None. Renal Ultrasound Possible indications include: Loin pain, haematuria, renal stones, renal pathology, hydronephrosis / obstruction, polycystic disease, congenital anomalies. Preparation: 4 hour fast from food. 2 hours prior to the procedure the patient should empty their bladder and then drink 4 glasses of water between this time and the time of their appointment. Their bladder should be full on arrival in the department. If a catheter is insitu within the bladder it should be clamped 2 hours prior to the appointment. Children: 1-2 glasses of water prior is adequate. Post procedure care: None. Pelvic Ultrasound Possible indications include: Lower abdominal pain, uterine pathologies eg. fibroids, irregular / painful menses, ectopic pregnancy, ovarian pathologies. eg. cysts, appendicitis. A trans-vaginal scan will be offered to all suitable patients after a transabdominal examination, and after gaining informed consent. See notes below. Preparation: Two hours prior to the procedure the patient should empty their bladder and then drink 4 glasses of water between this time and the time of their appointment. IV fluids should be considered if the patient is an inpatient and unable to drink. Their bladder should be full on arrival in the department. The transvaginal scan is performed immediately after emptying the bladder. If a catheter is insitu within the bladder it should be clamped 2 hours prior to the appointment. Post procedure care: None. Pelvic TV (Trans-vaginal) Ultrasound Possible indications include: This examination is offered for some pelvic examinations as a transvaginal scan provides more detailed information. It will not be performed on patients in an altered conscious state or after medication for pain relief. Informed consent from the patient is compulsory. See notes below. Indications as for pelvic ultrasound. Page 33 of 53 33 Preparation: 2 hours prior to the procedure the patient should empty their bladder and then drink 4 glasses of water between this time and the time of their appointment. IV fluids should be considered if they are an inpatient and unable to drink. Their bladder should be full on arrival in the department. If a catheter is insitue within the bladder it should be clamped 2 hours prior to the appointment. The transvaginal scan is performed immediately after emptying the bladder. Post procedure care: None. Transvaginal Ultrasound Information This examination will only be performed with the patient’s consent. The transvaginal examination gives increased detail compared to the transabdominal scan. A transvaginal scan will be offered to all suitable patients after a transabdominal examination. Transvaginal scans may be performed on patients older than 18 years of age ( as a general rule ) and those able to give informed consent. (Those patients given pain relief using certain medications may not be able to give adequate informed consent. Please consider this prior to medicating patients). Transvaginal scanning uses a specially designed, sterile-covered transducer, which is about the size of a large tampon. This transducer is lubricated and inserted into the vagina, usually by the patient themselves whilst being fully covered by a sheet or blanket. The procedure is normally painless and not as uncomfortable as a pap smear. The examination will be stopped at any time if requested. A nurse may accompany the patient during the procedure at the patient’s request. Transvaginal scanning has a number of advantages: 1. The patient does not require a full bladder. 2. More detailed images are obtained as the transducer is closer to the organs being scanned. 3. The scanning time is reduced as the organs can be quickly identified. The patient has the option to refuse this technique or discuss it with their doctor. NOTE: During the scan the transducer will be moved and rotated to ensure adequate images are obtained. The patient may feel some slight pressure while the ovaries are being scanned. However, most women who have had both trans-abdominal and transvaginal scan find the transvaginal scan not too uncomfortable. Obstetric Ultrasound – less than 15 weeks gestation. Possible indications include: Staging, pregnancy morphology, pain, bleeding, trauma A trans-vaginal scan may be occasionally indicated in addition to trans-abdominal scanning. This will only be performed on suitable patients after gaining informed consent. See above for details regarding the transvaginal scan. Preparation: A full bladder is required. glasses of water. Empty the bladder 2 hours prior to the procedure then drink 2-3 No videos of the ultrasound are performed. weeks gestation. Photos are provided free of charge after 12 Page 34 of 53 34 If twins are suspected please inform the Radiology Department as the examination will take longer to perform. Post procedure care: None Obstetric Ultrasound - after 15 weeks gestation. Possible indications include: Pregnancy Morphology, gestational staging. A trans-vaginal scan may be occasionally indicated in addition to trans-abdominal scanning. This will only be performed on suitable patients after gaining informed consent. See Pelvic TV above for details regarding the transvaginal scan. Preparation: A full bladder is required. glasses of water. Empty the bladder 2 hours prior to the procedure then drink 2-3 No videos of the ultrasound are performed. Photos are provided free of charge. If twins are suspected please inform the Radiology Department as the examination will take longer to perform. Post procedure care: None. Obstetric Ultrasound – 12 week / Nuchal Translucency Possible indications include: Fetal growth anomaly scan. Fetal age must be between 12 weeks and 13.5 weeks. The examination gives risk factors for Trisomy 13 / 18 / 21. Other anomalies are also assessed. The Nuchal Translucency may be combined with a Blood Test. The blood test is best performed during the 10th week of pregnancy. This will give a combined risk factor for Trisomy 13/18/21 and is a more sensitive test than just the Ultrasound alone. A trans-vaginal scan may be occasionally indicated in addition to trans-abdominal scanning. This will only be performed on suitable patients after gaining informed consent. See Pelvic TV Ultrasound for details of the transvaginal scan. Preparation: Two hours prior to the procedure the patient should empty their bladder and then drink 4 glasses of water between this time and the time of their appointment. Their bladder should be full on arrival in the department. Post procedure care: None. Ultrasound of Small Parts This covers a wide range of anatomical areas. These include : Neonatal hips, neonatal head (cranial), Shoulder (rotator cuff), tendons, eg. Achilles, soft tissue, eg. muscles, foreign body, thyroid, breast, salivary gland or testes (scrotal). Page 35 of 53 35 Possible indications include: As indicated. Preparation: None required. Post procedure care: None. Arterial Leg Doppler Possible indications include: Claudication, ischaemia, acute arterial thrombosis, follow-up of arterial interventional procedures. Eg. bypass graft surgery. Preparation: One Leg. 12 hour fast. 1 hour scan Both Legs. 12 Hour fast. 1. 5 hour scan. Post procedure care: None. A/V Fistulogram Possible indications include: Pre op work up. Assessement of flow of an A/V fistula either during or prior to haemodialysis. Eg. loss of “thrill”. Preparation: None. Post procedure care: None. Aorta or IVC (Inferior Vena Cava) Ultrasound Possible indications include: AAA, thrombus, tumour, dissection. Preparation: 12 hour fast. Post procedure care: None. Page 36 of 53 36 Doppler Abdomen Possible indications include: AAA, portal hypertension, mesenteric disease. Preparation: 12 hour fast. If mesenteric disease is indicated a scan after food may be undertaken. Post procedure care: None. Doppler Renal Possible indications include: Hypertension, suspected renal artery stenosis, transplant. Preparation: 12 hour fast. This procedure may take up to one hour. of the preparation Laxatives should be given the night before as part Post procedure care: None. DVT Ultrasound - Leg Veins Doppler Possible indications include: Suspected DVT, follow-up for known DVT. Preparation: One Leg. No preparation required. Half hour scan Both Legs. 12 Hour fast. One hour scan. Post procedure care: None. Echocardiogram Possible indications include: Valvular / myocardial disease, congenital abnormalities, TIAs, tumours. Preparation: None required. This procedure takes about an hour. Post procedure care: None. Page 37 of 53 37 Varicose Veins Ultrasound - Doppler Possible indications include: Marking of veins prior to surgery, checking of perforator veins, venous ulcers, venous incompetence. Preparation: None required. One leg may take up to ninety minutes to scan. scanned at least two hours are required. If both legs are to be Preoperative scans may be used to mark on the patient’s skin for the location of veins. Eg. Prior to bypass surgery Post procedure care: None. Liver Biopsy – Ultrasound Guided Possible indications include: Pathological review of liver structure. Preparation: Four hour fast. Patient is booked as a day procedure. Clotting times are required. If there is any risk of an abnormal clotting profile this should be checked prior to the biopsy being performed. Post procedure care: Patient returns to the ward with a post care instructions. hour stay following the procedure. There is a minimum of a four (4) US Guided Ascitic Tap - Abdominal Paracentesis Possible indications include: Pathology, symptomatic relief. Preparation: Four hour fast. Patient may be booked into the hospital at the discretion of the requesting medical practitioner. This is often performed on an outpatient basis. The patient must be aware of the need to rest for the remainder of the day if they are returning home. If there is any risk of an abnormal clotting profile this should be checked prior. Post procedure care: See Nursing Service Clinical Practice Guidelines. albumin replacement should be arranged. If ongoing drainage has been requested If the procedure is being performed on an outpatient basis the patient is kept in the department resting for approximately an hour prior to being released into the care of another person. Lunch or a drink will be provided. Page 38 of 53 38 US Guided Breast Cyst Aspiration or Lesion Biopsy Possible indications include: Pathology. Pain relief. Preparation: Previous breast ultrasound / mammograms must be available. Four hour fast. Post procedure care: Family member / friend to drive patient home if required. bruising. Ice may be applied to decrease US Guided Breast Cyst Aspiration or Lesion Biopsy Possible indications include: Pathology. Pain relief. Preparation: Previous breast ultrasound / mammograms and reports must be available. Four hour fast. An US Guided breast Biopsy is performed as an Outpatient. Post procedure care: Family member / friend to drive patient home if required. bruising. Ice may be applied to decrease US Guided Breast Hook Wire Localisation Possible indications include: Breast mass. Preparation: Patient must be an inpatient and due for theatre that day if a Hook Wire Localisation is being performed. Previous breast ultrasound, with or without a mammogram must have been undertaken. The previous films and reports must be available. The lesion must be clearly visible under ultrasound. The patient will leave the radiology department with the hook wire insitu. Post procedure care: Continue preparation for theatre. US Guided Thoracentesis - Pleural Tap Possible indications include: Pathology, symptomatic relief. Preparation: Four hour fast. Page 39 of 53 39 Patient may be booked into the hospital at the discretion of the requesting medical practitioner. It may be performed on an outpatient basis. The patient must be aware of the risk of having to stay in hospital overnight and needing to rest for the remainder of the day if they return home. Clotting times are required. Post procedure care: See Nursing Service Clinical Practice Guidelines. If the procedure is being performed on an outpatient basis, the patient is kept in the department resting for approximately an hour prior to being released into the care of another person. Lunch or a drink will be provided. US Guided Thyroid Cyst Aspiration or Lesion Biopsy Possible indications include: Thyroid mass Preparation: Four hour fast. Previous thyroid ultrasound must be available. Clotting profile is required. Post procedure care: Family member / friend to drive patient home if required. bruising. Ice may be applied to decrease MRI Scanning Magnetic Resonance Imaging (MRI) is available on site by Ballarat MRI. The direct phone number is 03 5320 4311 for an appointment time. Office hours are 8.00am to 5pm Monday to Friday. You must have a specialist provider number to order these scans. What is MRI Magnetic Resonance Imaging (MRI) uses radio waves and a very strong magnetic field to make detailed images of the body’s internal structures. There are no known harmful effects from either the radio waves or the magnetic field on the human body. No X-rays are used. However, if the patient has had an electronic device (such as a pacemaker) or certain types of metal prosthesis implanted, the magnetic field may disturb these, with possible adverse effects. If your patient has any implants of any kind please talk to the MRI staff to ensure their safety. Many metal objects (like joint replacements) are quite safe. If the patient is unable to communicate and you are unsure of implant status, please arrange for some plain X-rays prior to scanning the patient to check for any implanted or foreign objects. Metal fragments in the eyes can move and cause permanent vision loss. If the patient thinks they may have metal fragments in their eyes, they will need a plain x-ray of the orbits to check prior to scanning. Preparing for the Test The patient, or a staff member on behalf of the patient, must fill out a ‘Patient Safety Questionnaire’ prior to scanning. If a staff member is entering the MRI scanning room they must also complete a Safety Questionnaire. Page 40 of 53 40 All people entering the MRI scanning room must remove any watches, metallic jewellery and patients should be in a hospital gown. Hair pins must be removed prior to scanning. Items such as credit cards, pages and mobile phones CANNOT be taken into the MRI scan room. Patient Preparation for MRI Scanning - All Areas Except Abdomen The patient may eat and drink normally on the day of the test. medication as normal. The patient should take any Patient Preparation for Abdominal Scanning A six(6) hour fast is required prior to MRI scanning of an Abdomen. Patient Preparation if Sedation is Required A four(4) hour fast is required when the patient believes they will require IV sedation to enable the scan to occur. Sedation needs to be booked with the MRI appointment to ensure that the necessary time and staff are available. If the patient has pain please give normal pain medication prior to MRI scanning, as the patient must remain still for a considerable period of time. Information on and Preparation for Sedation(sedation is not recommended for abdominal scanning) To ensure your safety, during and following sedation, please observe the following: 1. No food or drink for four (4) hours prior to your appointment. 2. You will require someone to drive you home. you. They must come into Ballarat MRI to collect 3. Please bring a list of any medications you currently take. 4. Inform the staff of any allergies prior to attending for your appointment. 5. Following your scan you will need to rest. drive a car for 12 hours. Make no plans to work, sign legal documents or 6. Before sedation is given, you will be asked to give consent. For further information please contact a member of the nursing staff on 03 5320 4270 What Happens During the Scan MRI is like a doughnut, with the patient lying on a table that passes into a tunnel (“bore”) that is in the centre of the machine (similar to a CT). The antenna(“coil”), which receives the radio waves used in MRI, will be placed next to the body part being examined. Special glasses and mirrors will be provided to see outside the bore of the magnet. During the examination a series of fairly loud tapping or buzzing will be heard. This is quite normal. Each series of images may last for a time between a few seconds and a few (up to 10) minutes. The normal total examination time is between 15 and 45 minutes. The patient must keep as STILL as possible otherwise the images will be blurred. (Remember the images are taken over a space of seconds to minutes) Pads and supports will be provided where possible to aid in the patient staying still. Headphones or ear plugs will be provided to minimise the noise and the patient is welcome to bring in a CD or tape of their own choice to listen to during scanning. This is not possible during abdominal imaging. There is an intercom system allowing the patient to talk to the person scanning and for them to talk to the patient and check how they are going. A friend or relative may sit in the scanning room, with the patient, if desired. Page 41 of 53 41 Some patients will require an injection of gadolinium (an MRI contrast agent) as part of the test. This is given via a small needle into an arm vein. It is not iodinated contrast and side effects are extremely rare however it can cause Nephrogenic Systemic Fibrosis (NSF). THEREFORE: A current estimated glomerular filtration rate (eGFR) is required in the following patients before gadolinium can be given. Patients over 70 years of age Patients with pre-existing renal impairment Patient with diabetes After the Test There are no after-effects from the test. Patients who have required sedation need observation for this and will be provided with instructions. The images take time to interpret and results may take from 3-5 working days. Page 42 of 53 42 Mammography Mammograms are performed at Ballarat Health Services by the staff of Lake Imaging. this procedure please call 132050 To book Possible indications include: Routine check,strong family history of breast disease, palpable lump, follow-up of known lesion. Preparation: No Talcum powder, deodorant or perfume to be worn around the chest or underarm area. Patients will feel more comfortable if they wear a skirt and blouse or trousers and a shirt. Asymptomatic, pre-menopausal women should be booked to coincide with the first ten days of their period. Post procedure care: None. Needle localisation of Breast Lesion Possible indications include: Mass shown on mammogram which is not palpable. Preparation: Patient must be an inpatient and due for theatre that day. Post procedure care: Continue preparation for theatre. Page 43 of 53 43 Restricted Medication It is recommended that the following drugs are ceased 48 hours before a Myelogram or CT spine with intra thecal contrast examination is undertaken and should not recommence until 24 hours after the examination. This is not an exhaustive list and is only an indication of the medications which may lower the seizure threshold. Tricyclic Antidepressants Generic Name Desipramine Amitriptyline Doxepin Mianserin Trimipramine Clomipramine Dothepin Imipramine Nortriptyline Trade Names Pertofran Endep Mutabon D Tryptanol Deptran Sinequan Tolvon Surmontil Anafranil Dothep Prothiaden Melipramine Tofranil Allegron Nortab Phenothiazines and related Medications Generic Name Thiothixene Fluphenazine Decanoate Fluphenazine Hydrochlorice Perphenazine Prochloroperazine Promethazine Thioridazine Trifluoperazine Droperidol Haloperidol Pericyazine Pimozide Chlorpromazine Thiethylperazine Trimeprazine Promazine Trade Names Navane Modecate Anatensol Dalmane Mutabon D Trilafon Compazine Sternatil Avomine Phenergan Prothazine Aldazine Melleril Parstelin Stelabid Stelazine Droleptan Serenace Haldol Neulactil Orap Largactil Torecan Vallergan Sparine Mono Amine Oxadise Inhibitors (MAOI) Generic Name Tranylcpromine Phenelzine Central Nervous System Stimulants Trade Names Parnate Nardil Generic Name Trade Names Methylphenidate Tacrine Ritalin Page 44 of 53 THA 44 APPENDIX: PROTOCOLS Renal insufficiency and contrast media. Metformin and contrast media. Premedication of patients with known iodinated contrast reaction. Extravasation of contrast media. Page 45 of 53 45 PROTOCOL Renal Insufficiency & Contrast Media SCOPE (Area): Radiology & Acute SCOPE (Staff): Radiology , Medical & Nursing Staff BACKGROUND/RATIONALE Contrast-induced renal failure is a major potential side-effect of radiographic contrast injection Principles of safe contrast administration include: Contrast should only be given when necessary and the dose should be as low as possible High risk patients such as those with diabetes mellitus, myeloma or preexisting renal disease have a known incidence of contrast induced real failure which may be as high as 50% Reduction of Risk of Contrast Administration: Acetylcysteine (Mucomyst) administration was believed to significantly lower the risk of renal failure in high risk patients but results of subsequent studies have been inconsistent and its current position is not completely resolved. However, the relative safety and inexpensive cost of acetylcysteine favour its use at the present time. Intravenous hydration is most widely recommended prophylactic measure, to reduce the incidence of contrast induced renal failure, however there is little clinical data to support timing and amount of hydration. Iso-osmolar contrast media Visipaque (Iodixanol) may lower the risk of contrast induced renal failure. This may be due to reduced renal vasoconstriction because it has the same osmolarity as plasma. Estimated Glomerular Filltration Rate (eGFR) is now considered to be the most accurate indicator of renal function, as it factors – in the patients age and sex. NOTE: eGFR is considered unreliable in the following: Children <18 years, Aboriginal, Torres Straight Islanders, Asian populations, acute renal failure and dialysis dependant patients, extremes of body size, severe liver disease, diseases of skeletal muscle, paraplegia, amputees, pregnancy. The injection of radiographic contrast agents is completely containdicated in renal failure, when the eGFR is less than 30mls/min, with the exception of patients where renal dialysis has been scheduled post procedure or a nephrologist or physician has been consulted. EXPECTED OUTCOME Patients with an eGFR < 50ml/min will be administered iso-osmolar contrast media Visipaque. Page 46 of 53 46 Preparation is recommended (see below) for patients who have pre-existing renal failure with a eGFR below 50mls/min and other co-morbidities such as diabetes, cardiac failure, myeloma, thyrotoxicosis and increased age (above 65 yrs) All Patients having contrast media need to be encouraged to increase their fluid intake in the short term. ACTIONS 1 . Saline intravenously, at a rate of 1ml per kilogram of body weight per hour, for the 12 hours prior to and the twelve hours following administration of the contrast agent. 2. Optional- Acetylcysteine (Mucomyst) orally, at a dose of 600mg twice a day on the day prior and the day of administration of the contrast agent. 3. The patient should continue to be encouraged to drink extra fluid if possible. 4. Nonionic, iso-osmolar contrast agent (Visipaque) is used in the smallest possible dose for the procedure (preferably not greater then 75ml if the study allows) 5. Occasionally, due to renal failure or other causes such as cardiac failure, rehydration is not possible. In such an event, the lowest possible dose of Visipaque may be used, providing the eGFR remains above 30ml/min. We understand that there would be an increased cost associated with the patient being admitted to hospital for a 24 hour period. The true saving is the decrease in the risk of patient morbidity and decreasing the risk of patients requiring an increase in the length of their hospital stay or admission following outpatient injection of contrast agent without preparation. To assist us in our efforts to reduce the complications of administration of contrast media please have a recent eGFR available and inform our staff of any patient who has an eGFR below 50ml/min. We want to offer the best available service to your patients. RELATED DOCUMENTS Internal Radiology – Procedures & Preparations – MAN/004/V1 REFERENCES Tepel M., Aspelin et al, (2006). Contrast induced nephropathy- A clinical and evidence based approach. Circulation, April 11 Issues in the use of contrast media in patients at high risk for contrast-Induced Nephrotoxicity (Joint activity sponsored by Interlink Healthcare communications) June 2003. Trivedi HS. et al, (2003). A randomised prospective trial to assess the role of saline hydration on the development of contrast nephrotoxicity. Nephron Clinical Pract:93. Y-C Hsieh et al, (2006). Iso-osmolar contrast medium better preserves short and long term renal function after cardiovascular catheterisation in patients with severe baseline insufficiency. International Journal of Cardiology Page 47 of 53 47 Lameire N, (2007). Screening of Renal Fuction Prior to Administration of Iodiated Contrast Medium C212. Volume V Issue 2. Reg. Authority: CEO, Executive Directors-Nursing, Date Effective: Sept 2007 Medicine, Allied Health & Psychiatric Services. Date Revised: May 2009 Director of Radiology. Date for Review: May 2012 Review Responsibility: Radiology Original Author: Director of Radiology & NUM – Radiology (2007) Updated by: Director of radiology & NUM – Radiology (2009) PROTOCOL Metformin & Contrast Media SCOPE (Area): SCOPE (Staff): Radiology Radiology Staff BACKGROUND/RATIONALE Following the review of the available literature and taking into consideration the Royal Australian and New Zealand Collage of Radiologists Policy on this subject, the following protocol is recommended for the care of patients prescribed Metformin Hydrochloride and being given contrast media. ACTIONS RENAL FUNCTION PRIOR TO CONTRAST MEDIA The ordering medical practitioner is responsible for ensuring that the renal function has been checked prior to the patient attending the Radiology Department. This may be undertaken by recording on the radiology request a normal eGFR that has been obtained within the previous 12 months, or by undertaking a new eGFR. Please record the pathology laboratory undertaking this test on the request slip. NORMAL RENAL FUNCTION AND METFORMIN There is a theoretical risk of Metformin induced lactic acidosis following intravenous contrast being given. Metformin is to be ceased for 48 hours following injection with contrast media to allow for full clearance of the contrast prior to the recommencement of Metformin. No medical follow-up is recommended. Page 48 of 53 48 ABNORMAL RENAL FUNCTION AND METFORMIN Metformin will be ceased for 48 hours following injection with contrast media. At 48 hours the patient requires a review by their medical practitioner, and their eGFR levels rechecked. Metformin should not be recommenced before normal eGFR levels have been confirmed. (Metformin and Contrast Media are excreted through the same pathway in the kidney.) The Radiologist will record in the report and contact the local medical practitioner about Metformin being ceased. Patient Information Patients will be given a post contrast care sheet. can recommence their Metformin. This will explain when they For patients with abnormal renal function the sheet will also contain a followup appointment with their medical practitioner and an attached pathology request slip for a check eGFR level, which is to be undertaken prior to this appointment. Note Metformin includes: Chem Mart Metformin, Diabex, Diaformin, Gen Rx Metformin, Glucohexal, Glucomet, Glucophage, Metformin_BC, Terry White Chemists Metformin, healthsense Metformin RELATED DOCUMENTS Internal Radiology – Procedures & Preparations – MAN/004/V1 REFERENCES The Royal Australian and New Zealand College of Radiologists “Policies – Contrast 1.2 Metformin Hydrochloride and Intravenous Contrast Media Guidelines” http://www.ranzcr.edu.au/open/poll_2.htm Product information available via: MIMS Australia, Australian Prescription Products Guide and Australian Medicines Handbook. Reg. Authority: CEO, Executive DirectorsDate Effective: June 2003 Nursing, Medicine, Allied Health & Psychiatric Date Revised: Oct 2007 Services. Director of Radiology Date for Review: Oct 2010 Review Responsibility: Radiology Original Author: Director & NUM of Radiology (2003) Updated by: Director & NUM of Radiology (2007) Page 49 of 53 49 PROTOCOL Premedication of Patients with known Iodinated Contract Reaction SCOPE (Area): SCOPE (Staff): Radiology Radiology Staff BACKGROUND/RATIONALE Overseas Findings Studies undertaken by Laser et al. have demonstrated a decrease in reactions when two doses of oral steroids were administered prior to contrast injection. This showed that two doses of oral steroids prior to administration of contrast media did decrease the number and severity of the reactions. There was also a demonstrated decrease in allergic reactions when non-ionic contrast media was used. A study by Freed et al. medication) following a if the initial reaction breakthrough reaction. considered. looked into breakthrough reactions (oral steroid preknown reaction to iodinated contrast. They found that had been anaphylactoid there was a high risk of They recommended that other forms of imaging be These studies must remind us that even if we pre-medicate our patients, with a known history of contrast reaction, there is no guarantee of further reaction not occurring. The patient must be watched carefully and other methods of imaging considered. EXPECTED OUTCOME Following review of a number of articles relating to the area of contrast media reactions, the following information has been formulated to assist in the care of patients with a past history of reaction. DEFINITIONS Anaphylactoid Reaction: this reaction is triggered without prior sensitisation of the patient. Anaphylactoid reactions are not triggered by an IgE response. The reaction is identical to anaphylaxis. Anaphylaxis: this reaction is triggered by prior sensitisation of the patient, to a known allergen, causing the subsequent release of IgE. Categories of Reactions: Grade I – a single vomit, nausea, sneezing and vertigo. Grade II – hives, erythema, repeated vomiting, fever and/or chills. Page 50 of 53 50 Grade III – clinical shock, bronchospasm, laryngospasm, laryngeal oedema, loss of consciousness, convulsions, decrease in blood pressure, cardiac arrhythmia, angina, angioedema, pulmonary oedema. ACTIONS For patients with a known previous reaction especially of a grade II or higher level the following protocol should be observed. Oral prednisolone 25mg - 12 hours and 2 hours prior to the examination. If there is a history of a grade III reaction, an IV injection of hydrocortisone 100-500mg prior to injection of contrast should be considered. Patient observation is critical. RELATED DOCUMENTS Internal Radiology – Procedures & preparations – MAN/004/V1 REFERENCES Lasser EC, Berry CC, Talner LB, Santini LC, Lang EK, Gerber FH, Stolberg HO. (1987). “Pretreatment with corticosteroids to alleviate reactions to intravenous contrast material” The New England Journal of Medicine Oct. 1, Vol: 317 No: 14 pp: 845-849 Lasser EC, Berry CC, Mishkin MM, Winiamson B, Zheutlin N, Silverman JM. (1994). “Pretreatment with Corticosteroids to Prevent Adverse Reactions to Nonionic Contrast Media” The American Journal of Roentgenology March Vol: 162 pp:523-526 Freed KS, Leder RA, Alexander C, DeLong DM, Kliewer MA. (2001). “Breakthrough Adverse Reactions to Low-Osmolar Contrast Media after Steroid Premedication” The American Journal of Roentgenology June Vol: 176 pp: 1389-1392 Australian Medicines Handbook – sections on Allergy and Anaphalaxis. Reg. Authority: CEO, Executive DirectorsDate Effective: May 2002 Nursing, Medicine, Allied Health & Psychiatric Date Revised: Oct 2007 Services. Director of Radiology Date for Review: Oct 2010 Review Responsibility: Radiology Original Author: Director & NUM of Radiology (2002) Updated by: Director & NUM of Radiology (2007) Page 51 of 53 51 Ballarat Health Services PROTOCOL Extravasation of Contrast Media SCOPE (Area): SCOPE (Staff): Radiology Radiology Staff EXPECTED OUTCOME Following the review of the available literature, the following protocol is recommenced in the care of patients following extravasation of contrast media. ACTIONS Initial Treatment: Aspirate any contrast, via the cannula, if possible. Elevate the affected extremity, ensuring maintenance of blood flow. Ice packs (15-60 minute applications three times per day for 1-3 days) Close observation for 2-4 hours (if the volume exceeds 5ml) Phone call to the local doctor or hospital unit (if volume exceeds 5ml) Document all care on a Frequent Observation Chart (this is to be filled in the patient’s history or Radiology file) Surgical Consult (plastics if possible) if any of the following occur: Extravasated volume exceeds 100ml of nonionic contrast media Skin blistering Altered tissue perfusion (decreased capillary refill over or distal to the injection site) Increasing pain after 2-4 hours Change in sensation distal to site of extravasation. Surgical treatment may include: fasciotomy, irrigation with saline or hyaluronidase infiltration. Follow-up: If the out-patient has recovered a sufficient amount to go home then they are given a sheet listing the symptoms to be aware of (listed below): Residual pain Blistering Redness or other skin colour change Hardness Increased or decreased temperature of skin at the extravasation site (compared to skin elsewhere) Change in sensation If these have not resolved or are worsening with-in a 24 hour period they should contact their local doctor or attend at the Emergency Department for review. Page 52 of 53 52 Documentation: Frequent observation chart commenced documenting symptoms, treatment and discharge plan. Volume of extravasation, symptoms and treatment is documented in the Radiology Report. Post care sheet given and explained to the patient including when to call for follow-up. Notes: Conservative treatment should be all that is required. However, documentation is essential. In-patient – extravasation site care is undertaken by the referring unit. If the patient is an out-patient - the care is patient focused ensuring the general practitioner is aware of the incident. RELATED DOCUMENTS Internal Radiology – Procedures & Preparations – MAN/004/V1 REFERENCES Cohan Richard H, Dunnick N Reed, Leder Richard A, Baker Mark E. (1990). “Extravasation of Nonionic Radiologic Contrast Media: Efficacy of Conservative Treatment” Radiology Vol 176 Pp65-67 Cohan Richard H, Ellis James H, Garner Warren L. (1996). “Extavasation of Radiographic Contrast Material: Recognition, Prevention, and Treatment” Radiology Vol 200 Pps 593-604 Federle Michael P, Chang Paul J, Confer Scharmen, Ozgun Bertan. (1998). “Frequency and Effects of Extravasation of Ionic and Nonionic CT Contrast Media during Rapid Bolus Injection” Radiology Vol 206 Pps 637-640 Lang Elvira V, Valls Carlos. (1996). “What is the suggested treatment to minimize skin or subcutaneous injury if extravasation occurs when dynamic bolus CT is performed?” AJR Vol 167 Pp 277-8 Memolo Mark, Dyer Ray, Zagoria Ronald J, Pond Gerald D, Dorr Robert. (1993). “Extravasation Injury with Nonionic Contrast Material” AJR Vol 160 Pp 203-4 Sistrom Christopher L, Gay Spencer B, Peffley Linda. (1991). “Extravasation of Iopamidol and Iohexol during Contrast-enhanced CT: Report of 28 Cases” Radiology Vol 180 Pp 707-710 Reg. Authority: CEO, Executive DirectorsDate Effective: May 2003 Nursing, Medicine, Allied Health & Psychiatric Date Revised: Oct 2007 Services. Director of Radiology Date for Review: Oct 2010 Review Responsibility: Radiology Original Author: Director & NUM of Radiology (2003) Updated by: Director & NUM of Radiology (2007) Page 53 of 53 53