Chester Clinic

 

Microsoft word - body resident manual 2009-10 final 6-25-09 _2_

BODY IMAGING AND INTERVENTION 2009-10
William W. Mayo-Smith, MD Professor of Radiology, Warren Alpert School of Medicine, Brown University Director of Body Imaging & Intervention and CT Rhode Island Hospital Table of Contents I. General Description of the Body Division at Rhode Island Hospital a. Overview b. Body CT ii. CT Colonography iii. Coronary CTA c. CT Guided Interventional Procedures i. Biopsy and Drainages ii. Tumor Ablation Educational Goals and Objectives by Core Competency Body CT Resident Evaluation Reference Sources
I. General Overview and Description of Body Division

The Body Division at Rhode Island Hospital (RIH) interprets Body CT and MR exams
and also performs CT Guided Interventional procedures. The organizational structure of
the Department of Diagnostic Imaging at Rhode Island Hospital includes Medical
Directors of each modality, as well as Physician directors of each Organ System/Area.
The Medical directors of CT, MR and Ultrasound are Drs. Mayo-Smith, Rogg, and
Beland respectively.
The physician directors involved in the Body Division are as follows:
Director of Body Imaging & Intervention: Dr. Mayo-Smith
Director of Body MR:
Director of Fluoroscopy: Director of CT Colonography: Director of Cardiac Imaging (CT & MR) Director of Tumor Ablation:
CT at Rhode Island Hospital
There are currently six helical CT scanners at Rhode Island Hospital which perform in
excess of 75,000 examinations per year. The Main CT section has a 64 detector row
scanner which performs diagnostic and cardiac imaging and a single detector row scanner
with CT fluoroscopy for CT guided interventional procedures. There are two
multidetector scanners in the ER (64 and 16 detector rows). The Medical Office Center
(MOC) and the Pediatric Imaging Center each have a 16 detector row scanner. The
department uses dual phase power injectors for every contrast enhanced examination.
Resident and fellow exposure to CT occurs in the Body rotation, Emergency
Department, in Neuro, MSK and pediatrics. Computerized tomography is used within all
subspecialties of Radiology and this section will refer to the general daily operation of
residents rotating through the Body Section. Pediatric scans are performed in the Meehan
Building and interpreted in via our Picture Archiving System (PACs) by the pediatric
radiologists. Emergency CT scans are interpreted in the Emergency Department.
Body Rotation

The body rotation begins with rounding on patients in the hospital who have had tubes
placed by the CT/US radiologists. Any resident or fellow that has placed a tube in an
inpatient, should round on the patient to learn about follow-up catheter management. At
7:30 a.m. the resident/fellow reports to the Body reading room (Meehan 2) and pulls
cases from the CT Body worklist. In PACs, under the Subspecialty tab, there is the
"Body" Section, the subsections in this are "Body CT", " Body MR" and "Body Tube".
In addition, check the requisition bin adjacent to the door. (We are working on going
completely paperless by using the body worklist exclusively, but this system is not
completely integrated at this point.) " Tube rounds" take place at 8 a.m. to present and
discuss management of inpatients with catheters. The list of patients with tubes is on
the blackboard in the body reading room and worklist called "Body Tube." Exams to be
read during the day are CT studies that are on the Body CT" worklist. This includes
Abdomen and Pelvis exams, but will also include neck, chest, abdomen and pelvis exams
if they are performed on the same patient at the same time. (Individual chest exams are
read in the Chest Division and individual neck exams are read in the Neuro Division.)
The day concludes at 5:30 p.m. or when the work is completed, whichever is later.
Readout of Body CT and MR exams in the Meehan area is divided between the residents
rotating in the section and the cross-sectional imaging fellow. The senior resident (or
fellow) on the body rotation is responsible for performing the CT guided interventions for
the day.
The resident/fellow should review relevant prior exams on PACs to help with accurate
interpretation of the current exam. The resident/fellow should review prior discharge
dictations and relevant pathology and surgical reports from the Lifelinks computer
system. All residents and fellows are expected to have activated Lifelinks account which
are activated through the IT help desk (4-6381). The resident/fellow should then review
the films and form their own impressions. If you have a question about what is going on
with a patient, look up the history in Lifelinks and prior reports! The more history we
have, the better our interpretation will be. At this point, all cases will be reviewed with
the attending. At mid-day and at the conclusion of the day the resident/fellow should
review and sign all of their reports, making sure their queue is empty on the computer
system before leaving work. Any unexpected or emergent findings should be
communicated to the referring physician during the course of the day. All studies should
be dictated within 24 hours of the exam.
Second through fourth year residents are expected to be able to form basic interpretations
of thoracic, abdominal and pelvic examinations. These residents are expected to help
referring physicians interpret studies performed at Rhode Island Hospital when they
come to the Body section. When residents are having difficulty interpreting these cases,
the attending or fellow in the Body section should be consulted immediately.
Protocolling Cases

There is a comprehensive protocol book for CT examinations performed at Rhode Island
Hospital. These are also on line at the department web site or can be seen at
www.brownct.org. You can also Google "CT protocols" and our site is the first one
that comes up. Residents/fellows should read through the Rhode Island Hospital
protocols and be able to describe them in detail to the attending in the section. First year
residents should not protocol CT examinations. Please note that there is increasing
scrutiny about how radiological examinations are performed and there will need to be
careful attention to protocolling CT examinations. For example, if the history given is
"liver disease" then the appropriate examination is a three phase liver CT not an
abdominal CT. Likewise, if an abdominal CT is ordered, it does not necessarily mean a
pelvic CT should also be performed. If we perform a pelvic CT in this circumstance, we
will not be reimbursed for that study and in fact could be found guilty of over-billing
Medicare with a possible $10,000.00 per incident penalty.
The resident and fellow should protocol all upcoming cases in the morning and in the
evening before leaving for the day. All electively scheduled cases should be protocolled
at least 24 hours in advance.
When protocolling a case, the clinical history and prior findings of earlier radiology
reports should be acknowledged. The relevant results of prior study should be entered in
the appropriate portion of the CT protocolling sheet. On Friday, the resident should
protocol all cases for the upcoming weekend and Monday. If abnormalities are found in
the examination requested and prior studies, the referring physician should be called to
confirm the area of interest to be scanned. The resident/fellow should print their name
legibly at the appropriate position on the protocolling sheet so they can be contacted if
further information on the patient is needed.
CT Intravenous Contrast

Evaluation of Serum Creatinine before IV contrast Administration:
It is the policy of the Rhode Island Hospital CT Scan Department to check the serum
creatinine on all inpatients. The Patient Screening/Consent Form is completed for all
patients with the assistance of a technologist. If Cr > 1.5 OR if eGFR < 60 do not give
contrast unless the study absolutely, positively must be done. (Note that the eGFR is not
reported unless it is < 60)
If the study must be done, ensure adequate IV hydration with saline and consider the use
of Visipaque (although the evidence for its benefit is dubious.)
All out patients must fill out the Patient Screening/Consent form. A serum creatinine
level is not needed for outpatients.
All Emergency Patients will be treated as outpatients; hence, a screening serum creatinine
is not necessary for the performance of a contrast CT study. If the Ordering Physician is
concerned that the patient has renal failure, s/he should wait until the appropriate
screening blood work has been returned from the laboratory before ordering the CT.
Women and Infants inpatients that are accompanied by the patient's chart will have the
creatinine level checked and Patient Screening/Consent form completed. Patients from
Women and Infants Emergency Room are treated as outpatients.
Hydration Recommendations in Patients with Known or Suspected Renal Insufficiency (serum creatinine >1.5 or eGFR <60) Undergoing Contrast Enhanced CT Exam of the Abdomen/Pelvis*  CT requisition checked by radiologist to confirm that intravenous contrast required for clinical indication.  If intravenous contrast indicated, administer 500cc Normal Saline over 60 min before IV contrast.  Perform CT exam using 75cc Visipaque intravenous contrast  After CT Exam, administer 500cc Normal Saline over 60 minutes.  Radiologist to check patient after CT exam (for signs of failure) and encourage oral hydration (1-2 liters) day after exam * If patient at risk for congestive failure, use same volumes as above but use .45% Normal Saline. From: Katzberg, R. Lecture at ARRS Boston, 2009. Approved by Drs Goh and Dworkin from Nephrology Service 6/09. Contrast Types: We routinely use low osmolar intravenous contrast agents at a concentration of 350-370mgI/cc (omnipaque 350or Isovue 370) in adults. The technologist notes the volume of the agent and rate of injection on the PACs screen in the lower left corner. The volume of the contrast agent should be included in the dictation. For CTPE protocols, we currently use 100cc of 370mgI/cc (Isovue 370) at 4cc/second followed by a saline flush. For routine body work, we administer 130 cc of 350mgI/cc (omnipaque 350). This is given in a split dose (30cc intravenously, then wait 5 minutes, then 100 cc at 2cc/sec followed by saline flush. The purpose of the split does is to opacify the renal collecting system and bladder (the 30 cc delayed) and t he liver in the portal venous phase to detect liver abnormalities with one exposure to radiation. Visipaque 320 is a nonionic dimer shown to reduce the incidence of contrast nephropathy in high-risk patients. In patients with a serum creatinine of greater than 2.0 and in whom CT with contrast must be performed as an emergency (usually pulmonary CTA) .Visipaque may be used. In other patients with elevated creatinine and less urgent indications for CT it should be possible to perform a noncontrast CT or an alternative study such as ultrasound or MRI. Visipaque may be used in individual cases with the approval of the attending or if requested by the referring clinician. Note that Visipaque is of no benefit in prevention of idiosyncratic contrast reactions, and does not reduce the incidence of renal failure in patients who do not have an elevated creatinine. Visipaque is routinely used in coronary CTA exams due to its increased viscosity. Omnipaque 300 is used for all pediatric patients. The contrast volume for pediatric patients is determined by 1cc of iv contrast per pound of patient's body weight for patients less than 100 pounds. Pediatric patients weighing over 100 pounds will receive the adult contrast volume of Omnipaque 300. Intravenous Catheter sizes and policy: Intravenous catheters are started by the CT technologists or the IV team. The specific catheters to be used and the injection rates are summarized in the appendix. In general the injection rates depend on the type of contrast material and the catheter size. Omnipaque 300/350/370 intravenous access requirements: Injection rate of up to 2.4cc/second: 22 gauge or larger Injection rate of 2.5cc/sec to 4cc/second: 20 gauge or larger Injection rate of 4.1cc/sec or greater: 18 gauge or larger Visipaque 320 intravenous access requirements: Injection rate of up to 3cc/second: 20 gauge or larger Injection rate of 3.1cc/sec or greater: 18 gauge or larger CTA Scan Peripheral Intravenous Access Policy A 20 gauge or larger IV in an antecubital vein is preferred to perform a CTA study. Exceptions can be made at the discretion of the radiologist and technologist if a patient's current iv access can yield a quality study without reducing the injection rate. The rationale is to prevent extravasation and poor quality exams from inadequate intravenous lines. Central venous catheters can be injected depending on catheter type. Rates of injection also vary depending on catheter type. See appendix for details. Acute Contrast Reactions: Residents and fellows should be familiar with treatment of adverse contrast reactions and be able to treat the patient appropriately. The General Guidelines by Dr. B Murphy (6/09) are outlined below: Bronchospasm – Mild  Vital signs  Albuterol via spacer 8 puffs  Hydrocortisone 250mg IV Bronchospasm – Severe  Call code  If no cardiac contraindication: Epi Pen 1:1000, 0.3mg subQ  If circulatory collapse: Epinephrine 1:10,000, 3ml IV Hypotension – systolic 60-80mmHg  Vital signs, inc. pulse oximetry  Trendelenburg  1 liter N Saline IV in 15 min if normal heart rhythm  1 liter N Saline IV in 30 min if elderly/heart  Atropine 1mg IV if bradycardia, x2 if needed  CONSIDER CALLING CODE Hypotension - systolic <60mmHg  Follow same procedure as (systolic 60-80), If no response: Call code team - monitor rhythm  Sinus rhythm: Epinephrine 1:10,000, 5ml IV (repeat if necessary)  Hydrocortisone 250mg IV Urticaria  No Rx if mild and asymptomatic  Benadryl (Diphenhydramine) 50mg IV, if symptomatic (patient will need ride home.)  Auscultate chest to detect bronchospasm Severe Urticaria or Laryngeal Edema  Secure airway  Call code if intubation anticipated  Epi Pen 1:1000, 0.3mg subQ  Epinephrine 1:10,000, 1-5ml IV if vascular collapse Seizures  Protect patient from injury  OP airway if >2 min  Ativan (Lorazepam) 2mg IV  Neuro consult / ER transfer
Prophylaxis for Intravenous Contrast Reactions:
If a patient has a history of a serious contrast reaction and is scheduled for a CT scan with
contrast, then an alternative exam should be attempted (noncontrast CT, ultrasound or
MR). If contrast is required and there is a strong clinical indication, then the
premedication regimen recommended by the American College of Radiology should be
followed. Methylprednisolone (Medrol) 32 mg. p.o. 12 hours and 2 hours before the
contrast injection. In addition, the patient should receive low osmolar contrast material.
In general, H2 blockers (cimetadine) are not recommended. The above assumes the
patient does not have a contraindication to steroids (pediatric, pregnant, fungal infection,
diabetes, immunocompromised patients, lymphoma, leukemia, peptic ulcer).
Metformin (Glucophage):
Metformin (Glucophage) is an oral hypoglycemic for which precautions should be taken
when giving intravenous contrast. Our protocol for administering intravenous contrast in
patients on Glucophage is approved by the ACR and is as follows: 1) patients
undergoing intravenous contrast agents should stop taking Glucophage either before or at
the time of the contrast examination. 2) Patients should remain off Glucophage for 48
hours after their contrast study and then have a serum creatinine drawn. If the creatinine
is normal, the patient can resume medication. In the CT section, we will fill out a lab slip
for creatinine to be drawn with the results to be sent to the patient's referring internist.
The patient will be instructed to call their internist one day after the blood test to decide
whether the medication can be restarted. This will save a step for the patient and the
internist as the decision to restart the medication can be made by phone call rather than a
visit. 3) Patients with elevated creatinine (greater than 1.5) and on Glucophage should
have the contrast administered only if there is a high diagnostic yield to be obtained from
the contrast. 4) Note the patients do not need to be off Glucophage for 48 hours before
the contrast examination is started.
Contrast Extravasation:
Our policy for contrast extravasation follows ACR guidelines.
A staff physician (fellow or attending) should evaluate all extravasations. Evaluation
should include a neurological exam of the affected extremity, documentation of presence
or lack of capillary refill and skin ulceration and documentation of presence of distal
pulses and presence of pain. The patient should be observed in the CT suite for 2-4 hours
after the extravasation with the arm maintained in an elevated position above the heart.
The patient should be instructed to apply dry warm packs to the site of extravasation and
to keep the arm elevated overnight. For large volume extravasations (>50) the patient
should return to the Radiology suite the following day to the same physician. We do
NOT take x-rays of extravasated material in the arm.
If there were some findings at the time of the exam (increased pain or swelling),
decreased capillary refill, change in sensation or skin ulceration, a plastic surgery consult
should be obtained at the time of extravasation. If the extremity looks particularly
ominous and needs immediate attention, consult with the Emergency Department is
necessary.
As a courtesy, the patient's referring physician should be informed of the extravasation
and our management. The extravasation, physical exam and steps taken in management
should be dictated in the reports. An addendum can be dictated the following day when
the patient is seen in follow-up. If contrast extravasation does occur in the evening (from
5-11PM) when the resident is covering, the findings on physical exam and actions taken
should be written on the patients requisition and the details related IN PERSON to the CT
attending at 8 AM the following morning.
Contrast in Pregnant Patients:
The patient's referring physician needs to obtain informed consent (consent form in
appendix) before an intravenous contrast CT scan is performed in a pregnant patient.
Contrast in Mothers who are Breast Feeding:
A small amount of iodinated contrast is transiently excreted in breast milk. We ask the
mother to pump her breasts for milk in advance, then breast feed the baby immediately
before the CT procedure. She should perform the next feeding with pumped breast milk,
then resume normal breast feeding.
Radiation Dose Reduction
We employ protocols tailored to maximize diagnostic yield and minimize radiation
exposure. All CT units at RIH use an "auto-exposure" variable mA feature to lessen
dose. It is important to choose the correct protocol carefully as each protocol is designed
to minimize exposure. For example, a Renal Stone protocol uses lover dose than a
routine abdomen and pelvis because the calculi are radio-opaque and will be easily
visualized at a lower mA.

Scanning Pregnant Patients
All pregnant patients need an informed consent signed (by the patient and referring
physician) before any CT exam is performed. This situation arises primarily in the ER
and this policy has been approved by department chairs Drs. Cronan and Zink. A copy of
the pregnancy consent form is attached at the end of this document.


Scanner Weight Limits

Given the epidemic of obesity, residents are frequently asked about the weight limits of
our scanners: Scanners in the department have a weight limit of 450 pounds. The VCT
unit in the Meehan and ER has a weight limit of 500 pounds.
Dictations

Dictations are now being performed using the voice recognition software Powerscribe.
Dictations should be performed and signed at the end of the day. Dictations in CT should
include the relevant patient history, pertinent other studies and the CT technique. The CT
dictation should include the volume of low osmolar contrast was administered. The body
of the report should include the pertinent positive and negative findings given the clinical
history. The conclusion should be short and have a new sentence for each important
impression. Due to legal issues and appropriate reimbursement, multiple CT
examinations in one patient should be dictated in separate paragraphs. For accuracy of
communicating the aggregate results, the conclusion of the dictation should contain the
results of all the CT examinations performed. Thus for a chest, abdomen and pelvis CT
to follow-up for lymphoma the dictation should read as follows:
"The patient is a 35-year-old male with lymphoma treated with chemotherapy, question recurrent disease. Helical scanning using multidetector row CT was performed from the lung apices through the pelvis after dynamic administration of 130 cc of low osmolar contrast material. Comparison is made with prior CT from 5/15/02. CHEST: The lungs are clear. There is no evidence of hilar or mediastinal adenopathy. The heart and bones are normal ABDOMEN: The liver, gallbladder, pancreas, kidneys and adrenal glands are normal. The spleen remains enlarged measuring 20 cm in cranial-caudal dimension. There is no evidence of retroperitoneal adenopathy. The bowel within the abdomen is normal. PELVIS: There is new left iliac adenopathy with the largest node measuring 3 cm. The bowel, bladder and bones are normal. Dr. has reviewed the report and all images related to this patient encounter. IMPRESSION: 1. Stable splenomegally New left pelvic adenopathy since prior exam suggesting recurrent lymphoma
Regulations put forth by CMS (Center for Medicare/Medicaid Services) require that
residents and fellows attest to the participation of attendings in the work product. For
diagnostic imaging that product is the report. Thus please add the following sentence at
the end of the finings (NOT the conclusion) of every report. "Dr. has reviewed
the report and all images related to this patient encounter."
Important or unexpected clinical findings should be called to the referring physician
at the time of the dictation. It can be difficult to contact the referring resident when
the patient is followed in Medical and surgical clinics . below is a list of the contact
nurses for various clinics (as of 4/08):
Adult Medical Primary Clinic:
Contact: Rhonda Alpha Pager:
350-0791

Adult Medical Specialty Clinics:
Contact: Deborah
Alpha Pager: 350-7852 Adult Surgical Specialty Clinics:
Contact: Mary
Alpha Pager: 350-7847
Bridge ED:
Nancy Towers, RN, Director Extension:
255-5734
Charge Nurse Nextel phone; if line is busy call 4- 5411 and ask to be connected to the ACM on duty.
There is a QA "Red Results" departmental policy for emergent unexpected findings
which is outlined below:

Red Results Procedure (updated 5/07):
If any of the following Critical Abnormal Results are discovered by the radiologist during the interpretation of an imaging exam, and it is not indicative of a known existing or improving condition, the result will be communicated within the shortest time possible to the ordering physician or covering LIP that can facilitate the appropriate course of therapy or treatment for the patient. For all
telephonic reporting of these critical results, the person receiving the test result
must "read-back" the complete result. Every attempt will be made to
communicate the results within one hour of detection.
As part of the reporting process the radiologist will dictate the exam as soon as
the abnormal result is discovered and in the impression include the abnormal
result, the name of the ordering physician or LIP that was contacted and who read
back the result, and the time the call was placed. The final impression must
contain the words RED RESULT in the first 320 characters. The Radiology
System will then be searched for all reports with critical values for Quality
Assurance purposes. Results of Quality Assurance monitoring will be reported
monthly in the aggregate. The results of any individual retrospective case reviews
will be non-discoverable pursuant to the Rhode Island Medical Malpractice Act,
section 23-17-25 and such laws which supplement or replace it.
RED Critical Abnormal Result List:
1) Tension Pneumothorax
2) Unsuspected significant hemorrhage
3) Critically misplaced tube or catheter
4) Acute pulmonary Embolism
5) Infection related soft tissue gas
6) Unexplained pneumoperitoneum
7) Ischemic bowel
8) Ectopic pregnancy
9) Midgut volvulus
10) Testicular/ovarian torsion
11) Acute Intracranial Process
12) Acute cord compression
13) Acute DVT

Access to RIMI Images and Shields Images via Synapse:

Occasionally we are asked to review images from RIMI or Shields, particularly to book a
patient for a biopsy. Residents should each have their own access code to synapse. To
get your RIMI account password, contact Kyle Schuster at RIMI cell 401-639-2968. To
view images on Synapse, you have to log in twice - once for one application (RIMI or
Shields) and a second time for the next application (RIMI or Shields). To do
this, select the folder tab at the top left that you're not logged into (RIMI or Shields) after
your initial log in displays the home page. There may be a slight delay when logging in
or bringing up images but have patience - it should work eventually.
Diagnostic Body CT Exams

General Protocol Information: We are routinely performing 5mm coronal reconstructions for neck, chest and abdomen on all MDCT exams. This offers more diagnostic information from routine scans without need to use the 3D workstation or archive large data sets. As residents review the studies, they should also consider if additional reconstructed images in other planes, or thinner slices through a certain region, could be beneficial in the interpretation of a study (i.e. thin slices though a pulmonary hamartoma, or sagital images for a skull base lesion, etc.) Residents can ask the technologist to reconstruct such images and forward them to PACS prior to attending readout. All abdomen/pelvis non trauma CTs now have a dual phase injection protocol of 30 cc contrast followed by 100cc saline. This is followed by a 5 minute delay, then injection of 100cc contrast and image at a fixed delay of 80 seconds. The rationale is to opacify the ureters and bladder with contrast (30cc up front, flush, 5 min delay), without obscuring liver lesions (only 40 cc up front and 100cc contrast given dynamically). This protocol avoids the duplicate delayed scans through the kidneys and bladder and thereby reduces radiation dose. CT Colonography: Kevin Chang has outlined the general policies of the CT Colonography protocols as follows: CT Colonography Protocol, Post-Processing, & Reporting Kevin J. Chang, MD Updated 4/1/08
Indications:

1. Incomplete or failed colonoscopy: This is currently the only Medicare
reimbursable indication. This may be secondary to a variety of factors including colonic tortuosity, nonvisualization of the colon proximal to an obstructing lesion, colonic spasm, diverticulitis, extrinsic compression, aberrant anatomy or scarring related to prior surgery. The reason for the failed colonoscopy should be mentioned in the dictation to get reimbursed. a. DO NOT SCAN SAME-DAY FAILED COLONOSCOPY PATIENTS IF THE REASON FOR FAILURE IS "INADEQUATE BOWEL PREP." These patients will need to be re-prepped to perform the exam on another day. 2. Contraindication to colonoscopy (eg. Anticoagulation which cannot be discontinued, significant medical/surgical complications from previous colonoscopy). When in doubt, get preauthorization. 3. Screening: Not yet covered by Medicare, regardless of family history or risk factors. Could be performed as an out-of-pocket exam in the near future. Covered by Blue Cross Blue Shield (BlueCHiP Medicare, BlueCHiP RiteCare, Blue Cross/CHiP Commercial) for v643, v1000, v1005, v1006, v103, v160, v12.72).
CPT codes: Category III (for tracking, not reimbursement; released 7/1/04)
0066T: CT Colonography, screening
0067T: CT Colonography, diagnostic. May undergo review for Category I status in the
near future.
ICD9 code: Must use v643 (Traditional exam, ie. conventional colonoscopy, not carried
out for other reasons) as the primary code to get reimbursed.
Patient preparation:
The most crucial aspect of performing a high-quality CT colonography exam involves a
thorough colon prep. The prep protocol used differs from traditional colonoscopy preps
in that instead of high volume "wet" preps involving GoLytely, a "drier" prep is used
which leaves less residual fluid in the colon allowing much better visualization of the
colon wall by CT. The only exception to this prep protocol would be a patient coming to
CTC on the same day as an incomplete colonoscopy (already prepped for traditional
colonoscopy). In general, these "dry" bowel preps are better tolerated by patients than
the GoLytely prep.
There is no need for IV contrast unless the cause of incomplete colonoscopy is an
obstructing neoplasm which has not yet been staged with a prior contrast-enhanced
CT of the abdomen and pelvis. In the latter case, following colonic insufflation and scout
topograms, perform the usual noncontrast low-radiation dose supine scan followed by a
prone scan using the routine IV contrast injection dose, injection rate, post-injection
delay, and radiation dose that we use for a typical single-phase abdomen/pelvis CT.
This scan volume should include the whole liver.
"Dry" bowel prep:
Patient to pick up LoSo Prep (or Fleet-1 Prep) and 30 cc Gastroview from Radiology
prior to the day before the exam.

1. 24 hours prior to exam: Clear liquid diet only + bowel prep (choose 1 below).
Avoid milk or dairy products. Patient may take regular medications.
Diet recommendations:
PLEASE AVOID
clear fruit juices, canned fresh fruits, raisins, dried fruits, fruits (no seeds, skin or membranes) prunes, prune juice, skins. decaffeinated: coffee (limited), fruit flavored drinks, tea, carbonated drinks bouillon/broth, strained soups gelatin, fruit ice, popsicle coconut, nuts, seeds, hard clear candies, fruits that are not allowed on this list Miscellaneous salt, pepper, jelly, sugar, cloves, garlic, seed spices, chili sauce, Bar-B-Q sauce, any strong flavored spice or sauce, mustard, jam, peanut butter, mayonnaise, marmalade LoSo Prep (EZ-EM, Westbury, NY). Take as directed. Low sodium content is safer for
those with CHF or hepatic insufficiency than a Fleet-1 Prep. (Miriam Hospital prep).
Mg-citrate + four 5 mg Dulcolax (bisacodyl) tablets the day prior to the exam 1 Dulcolax suppository the morning of the exam
Alternatively, a Fleet-1 Prep kit may be used if there is no history of cardiac or renal
failure. Take as directed. (Rhode Island Hospital prep)
45 mL phospho-soda + four 5 mg Dulcolax tablets the day prior to the exam 1 Dulcolax suppository the morning of the exam
2. If the patient has picked up Gastroview ahead of time, he/she should drink the 30 cc
bottle just prior to going to bed the night before the exam (for the purposes of fluid
tagging). This may be mixed with 8 oz of clear fruit juice or a carbonated beverage over
ice. If the patient has not taken the Gastroview the night before, the patient may drink 30
cc of Gastroview at least 2 hours prior to the CT scan. The patient will need easy access
to the restroom as this agent also acts as a laxative. If the patient is not able to wait 2
hours or Gastroview is not available, the exam may be performed immediately without
fluid tagging (however, fluid tagging greatly aids in visualization of polyps otherwise
obscured by retained fluid in the colon).

GE VCT Protocol:

The most crucial technical aspect of this study lies in adequate gaseous distension of the
entire colon. In general, a thin-collimation low-dose technique is employed in both
supine and prone positions following scout topogram confirmation of adequate colonic
insufflation.
1. Allow patient to use the restroom immediately prior to positioning on the CT
table to empty bowel one last time. 2. Position patient in lateral decubitus position for placement of silicone rectal
3. Radiologist, nurse, or technologist to insert rectal catheter. Lightly inflate
balloon tip (20 cc air using syringe) in order not to distort mucosal anatomy of the rectal vault. Gently pull back balloon cuff flush with the anal sphincter. If there is any residual fluid present in the rectum, allow it to drain into the collection bag prior to attaching tubing to the insufflator. 4. Attach tubing to automated CO2 insufflator. Set PRESSURE dial to maximum
value of 25 mm Hg. Hit "FLOW STOP/RUN" button to begin inflation.
Inflation will ramp up slowly. If the patient experiences discomfort, hit the
FLOW STOP/RUN button to temporarily pause inflation until discomfort passes
then resume inflation by hitting the FLOW STOP/RUN button again. Position the
patient supine and then in the other decubitus position to help redistribute the
colonic gas.
5. Inflation is likely complete when: a. more than 2.0 L of CO2 has been administered and the volume display
is increasing slowly or remains unchanged
b. the pressure display is within +/- 2 mm Hg of the set point (23-27 mm
Generally, colonic distension requires 2-4 L of CO2 although more may be needed depending on the redundancy of colon and presence of small bowel reflux. If > 4.0 L of CO2 has been administered (which is quite common), the FLOW STOP/RUN button will have to be restarted to continue insufflation. FLOW STOP/RUN will also reset at every 2 L interval thereafter (safety feature). Excellent EZ-EM CO2 inflation video tutorial available at: http://www.ezem.com/virtual_colon/protoco2l_video.cfm 6. Position patient supine on CT table and perform end-expiratory CT scout
topogram. Evaluate scout for adequacy of colon insufflation. If not completely
inflated, roll patient to try to redistribute gas while continuing insufflation. Then
repeat scout.
7. Scan abdomen and pelvis from above the colon to lesser trochanters using a
single end-expiratory breath-hold with noise index of 50 at 1.25 mm collimation
and a 350 mAs maximum.
8. Confirm the colon prep and distension is adequate on axial images before
moving on to prone positioning. If the prep is inadequate, the exam should be terminated and the patient should be rescheduled for another day following a more thorough colon prep (Fleet-1 prep). Any colonic segments that are incompletely distended should be rechecked on prone images to insure an adequate exam. 9. Flip patient over prone while CO2 insufflator is still on. Position pillow(s)
beneath the patient's chest (and optionally pelvis) to relieve pressure on the abdomen and permit better distension. 10. When prone insufflation is complete (see criteria in Step 5), perform end- expiratory prone CT scout topogram to determine adequacy of colonic
distension (especially sigmoid). If not completely inflated, roll patient to try to
redistribute gas while continuing insufflation. Then repeat scout.
11. Perform prone scan using a noise index of 50 from above the colon through the
lesser trochanters in a single end-expiratory breath-hold. 12. Check adequacy of supine and prone axial images prior to removing catheter and
discharging patient. If a segment of bowel is not distended on supine and prone scouts (usually the sigmoid) then the exam will be non-diagnostic so repeat the scan in the right side down decubitus position to distend that segment.
13. Remove rectal catheter and have patient go to restroom to decompress colon
prior to discharge to home. No specific instructions are necessary as the patient may return immediately to regular activity. 14. Reconstruct supine and prone datasets to 1.25 mm collimation with 0.625 mm
overlap (1.25 x 0.625 mm) to send to GE Advantage Workstation and GE
PACS.

Post-Processing on the GE Advantage Workstation:

1. Choose patient from local database list and open supine and prone 1.25 x 0.625 mm datasets simultaneously using CTC Auto-Dissection plugin.
2. Edit lumen tracking for both supine and prone datasets if necessary.
3. Use Virtual Dissection 360 views for initial 3D screen.
4. Use 3D VR endoluminal views for correlation (shift-LMB on target).
5. 2D read for confirmation and to evaluate colonic surfaces beneath tagged
fluid: review axial images at "near-lung windows" (narrow windows enough to
barely differentiate fat from soft-tissue density) on supine and prone volumes.
Use coronal MPR as necessary to follow colonic lumen. Evaluate ALL surfaces
of colon on both supine and prone.
6. Placing bookmarks for the Reporting Tool greatly aids in generating multiple
reformatted images to send back to PACS ("DCBE" colon map, MPRs, 3D VR endoluminal views).
Reporting:

We will be following the CT Colonography Reporting and Data System (C-RADS,
Working Group of the 5th International Symposium on Virtual Colonoscopy, October
2004)1 for CTC reporting and management recommendations although we will not
necessarily use their numeric classification system as it is not yet recognized by
gastroenterologists, primary care physicians, or surgeons.
Polyps are defined as homogeneously soft-tissue attenuation structures arising from the
colonic mucosa demonstrating a fixed point of attachment to the bowel wall. A colonic
mass is defined as a similar structure measuring greater than 3 cm in largest dimension.
We will only report polyps 6 mm or greater in size. No polyps less than 6 mm should be
reported (in the body or impression of the report) as the specificity of CTC is limited at
this size (many of these represent adherent stool) and the clinical significance of polyps
of this size is also limited (most true polyps of this size are hyperplastic and do not
increase risk for developing colon cancer).
Polyp descriptors:
1. Size: in mm 2. Morphology: pedunculated, sessile (broad-based, width > height), flat 3. Location: (rectum, sigmoid, descending, transverse, ascending, cecum), also include distance from rectum in cm (on Virtual Dissection view) 4. Attenuation (i.e. fat = lipoma)
Extracolonic findings:
For a standard non-contrast CTC exam: "Limited non-contrast evaluation demonstrates
no significant extracolonic findings…"
Impression and Management recommendations:
1. Normal or Benign findings (i.e. lipoma, diverticulosis; no polyps ≥ 6 mm): routine screening (5 year follow-up CTC/endoscopy). 2. Polyps 6-9 mm, < 3 in number: 3 year follow-up CTC versus consideration of endoscopy (or repeat focused endoscopy). 3. Polyps 6-9 mm, ≥ 3 in number: Endoscopy. 4. Polyp ≥ 10 mm; Endoscopy. 5. Colonic Mass, likely malignant (compromises lumen or shows extracolonic invasion): Surgical consultation. A repeat directed endoscopy is often successful even when the initial endoscopy was incomplete. 1 Zalis ME, Barish MA, Choi JR, et al. Working Group on Virtual Colonoscopy. CT colonography reporting and data system: a consensus proposal. Radiology 2005;236:3-9. These guidelines are subject to consideration of the patient's history/presentation and local practice preference. We should call the referring physicians with the results of the CTC, especially with these first few cases as we need all the good PR we can get. If the patient asks to be called with the results, I will not hesitate to give them a call as well since satisfied patients will recommend this study to others as well as relate positive experiences to their own physicians. Questions, additional suggestions? Feel free to page me at 350-5841. -Kevin Cardiac CT Angiography: Mike Atalay has outlined the general policies of the Cardiac CT protocols as follows: 3/26/08 Cardiac CTA at RIH & TMH: How we do it
This document describes the basic principles and practice of Cardiac CTA angiography in general and as it pertains to our practice at RIH and TMH. With the
imminent installation of a 64-row MDCT in the RIH ED and the integration of cardiac
imaging into the Meehan world of body imaging, I believe that now is a good time to
review some of the basics. Hopefully this will promote interest, enthusiasm, and
understanding. Clearly, the details provided below will not be equally relevant to
everyone. Nonetheless, a fundamental understanding of how these studies are conducted
and interpreted may be useful in your discussions with patients and other doctors. It's and
exciting area of imaging. This is a small file, so feel free to keep it as a reference tucked
away in your email cyberworld.
1.
What is a cardiac CTA (CCTA)?
CCTA simply refers to CT angiography that provides motion free, high resolution images of the heart and the coronary arteries. When you consider the small size and
complex motion of epicardial coronary arteries, you begin to realize how amazing this
technology really is. Current techniques yield an isotropic resolution of 0.35mm,
allowing confident visualization and evaluation of vessels down to 1.5 mm in
diameter. In practice, CCTA is a subset of ECG-gated CTA, which is a better term for
way our studies are performed. The vast majority of cases of our cases are done as a
comprehensive survey of thoracic vascular anatomy and not specifically for coronary
imaging. The usual indication is "atypical chest pain". In essence, the protocol that we
employ is for the ‘triple r/o': We see with great clarity the thoracic aorta, the pulmonary
arteries, and the coronary arteries. If an exam is done properly, all artifacts associated
with cardiac and respiratory motion are eliminated. When you (or a referring
physician) want to see highly detailed, motion-free thoracic anatomy, ECG-gating is
the way to go. Because of the increased radiation of this technique, we are not currently
conducting all thoracic CTAs with ECG-gating, but I believe that in time we may be. The
aorta root motion artifact commonly seen on non-gated studies disappears with gating.
Aortic root abnormalities in particular (aneurysms and dissections) are identified and
diagnosed with greater confidence.
While the wizardry underlying the technology is largely opaque, the principles of ECG-gated CTA are quite straightforward. Image data are acquired simultaneously with the ECG. After the scan, all of the image data acquired at a particular point in the cardiac cycle (e.g. mid-diastole) are stitched together and used to reconstruct a 3-D image dataset at that cardiac phase. If the x-ray source is ‘on' throughout the exam, images can be reconstructed at every phase of the cardiac cycle, i.e. early/mid/late systole and early/mid/late diastole, and a movie loop showing the motion of the heart can be obtained. In practice, though we often obtain the information, we seldom pay much attention to the contractile function because the post-processing is labor intensive and the wall motion is usually well appreciated before we do the study (from echo/nukes/cardiac mri etc.). There are two types of ECG-gating: retrospective and prospective. I won't get into the details except to note the following: (1) With retrospective gating, the x-ray tube is on throughout the study and the scan trajectory is helical with a very low pitch ( 0.2 = 80% overlap with each gantry rotation). This method gives a relatively high dose of radiation, 13-15 mSv. This is comparable to a stress-rest MIBI study and substantially higher than a CT PE study which is 4-6 mSv. The RIH 64-row MDCT in Meehan currently only operates with retrospective gating. (2) With prospective gating, the x-ray tube is on only during a short window in mid-diastole and the acquisition is step-and-shoot: The gantry spins at one position, the tube goes on for a short burst, the data are acquired, the tube turns off and the gantry—still spinning—slides down 4cm (the thickness of 64-rows of 0.625mm thick detectors) and repeats. Data acquisition occurs every other heart beat so that the scanner has time to reposition. In GE ‘speak' this is referred to as ‘snapshot pulse'. A distinct and important benefit of prospective gating is that the radiation dose is much less than with retrospective gating—up to 70% less— and comparable to a CT PE study. This technique is only used when the heart rate is 65 bpm or less. The TMH 64-row MDCT has updated software that permits both retro- and prospective gating. Regardless or whether a study is performed using retro- or prospective gating, the acquisition is very fast and breath-hold times are usually 8 seconds. Based on the maximum rotation speed the CT gantry (3x/sec for our 64-row MDCTs), the effective ‘shutter speed' of data acquisition is 175ms. This is the temporal
resolution—in contrast to the spatial resolution referred to above. This means that for
motion-free imaging, the heart must be quiescent for a period at least this long. This is
why high-quality imaging is so heart rate dependent. Slower heart rates have longer
quiescent periods and in essence more room for error. In fact, in our experience, heart
rate is the single most important determinant of study quality and the ease of
analysis. A good study makes life much more pleasant. Without question, the lower
the heart rate the better the study. 65 bpm is the cut-off for a reliably good study. If
the heart rate is any higher, we'll have to contend with vessel motion. We're forced to
dig— sometimes deeply!— into our arsenal of post-processing tools. This can be
cumbersome and labor intensive. To give you some idea, a good, normal study can be
post-processed and interpreted in less than 10 minutes. An artifact-riddled normal study
can easily take 30 minutes. Add to that extensive coronary disease and you're sunk. We
will scan patients at heart rates higher than 65 bpm (up to 75 bpm) if all reasonably
options for reducing HR have been exhausted. See Nursing section below.
Thanks for your attention. I'm always open to comments and feedback. Booking Patients
 Elective studies should be scheduled Tuesday-Friday in the morning.
Exceptions are always possible but the cardiac attending needs to be aware! For the moment there are 3 of us.  Michael Atalay: 350-4322  Kevin Chang:  David Grand:  Who is eligible? o Evaluation of detailed cardiovascular anatomy
 Aortic root aneurysm or ?dissection
 Detection of subtle or questionable PE
 Pulmonary venous anatomy pre-/post RF ablation for
atrial arrhythmias
o Atypical symptoms
o Bypass graft patency
o Stent patency: If the stents are large ( 3mm diameter) and
proximal in the coronaries then we have a good chance of being able to confidently comment on their patency. If they're small & distal, we don't do well. o Equivocal stress test results o Cardiomyopathy with low or intermediate suspicion of CAD o Pre-op evaluation of patients for non-cardiac surgery o Pre-op evaluation of pts (over 40 y/o) for valve surgery o Anomalous arteries, fistula or CA aneurysms o If a referral specifically requests that we perform a cardiac CT to evaluate the coronary arteries, then we are obligated to bill as such using one of the test CPT billing codes (see below. These are the ones that end in 'T'). While Medicare supposedly pays for these codes, no other insurer in the RI does, and either the patient will get a huge bill or the Hospital will be forced to eat it.  0144T Coronary calcium scoring: CAC (non-contrast)  0145T Cardiac structure and morphology  0146T Coronary angiography w/o CAC  0147T Coronary angiography w/ CAC  0148T Card structure & morphology & coronaries  0149T Card structure & morphology & coronaries & CAC  0150T Card structure & morphology in Cong Heart Dz  +0151T includes 3D image post-processing, fxn & wall  71275 CTA chest  71260 CT chest with contrast ICD-9 codes  786.50 chest pain, unspecified  786.51 precordial pain  786.52 painful respiration  786.59 chest discomfort/tightness  787.7 abnormal chest sounds WHILE BOOKING ask screening questions (with answers!!) FOR PATIENTS &
REFERRERS:
 Renal failure o CHECK Creatinine (<1.5 mg/dl) if  All inpatients  Out-pts w/ known renal insufficiency  Out-pts w/ known diabetes  Out-pts > 60 y/o  Contrast allergy that has failed a prior pre-med protocol  Asthma o Most still tolerate beta-blocker. If not, verapamil.  Acute chest pain (stable angina under a physician's care and atypical chest pain are OK)  Atrial fibrillation, bigeminy, trigeminy, high grade heart block  Pacemaker: Artifact from right atrial appendage lead  Morbid obesity Tell patients:  No caffeine for 12 hours prior to exam  No smoking or eating 2 hours before exam (optional)  Ask if: allergy to nitroglycerin or on Viagra (do not give nitroglycerin)  Arrive 1 hour before study to register and take beta-blocker Insurance verified before patient arrives

Goal is Heart Rate less than 60!!
 Rhythm strip (for atrial fibrillation, heart block) in recovery room  Heart rate/pulse ox  Check BP before study and before discharge from CT area. Observe all
outpatients for 30 min after study. Notify doctor if ≥15 mmHg drop or
systolic BP ≤ 80 mmHg
 Outpatients: Everyone gets Beta-blocker except
(1) active asthmatics (i.e. wheezing or daily requirement of inhaler) (2) known significant aortic stenosis &/or insufficiency (3) Resting heart rate <60 bpm (4) Active CHF  Inpatients: Floor team needs to be responsible for getting the HR to acceptable level.  IV heplock 18 g or 20 g before they enter room, antecubital vein only (NOT hand), left arm better than right  Patient with HR of 60 and systolic BP > 110, give 2.5 mg Lopressor IV at  Heart rate > 60 and Systolic BP > 105, give 5 mg lopressor IV at  May repeat every 10 minutes x 4 if SBP BP > 90 or no absolute drop in SBP BP of ≥ 40 mm/Hg.  Half-life of IV lopressor is 3-7 hours, so before discharge take BP and monitor for orthostatic hypotension. If needed, can give some IV fluids, but notify Cardiac CT M.D./resident/cards fellow  For active asthma patients, page Cardiac CT M.D. The drug of choice is verapamil IV 10mg over 2 minutes and may be repeated x 1. Half-life of IV verapamil is 2-4 hours. Again check for orthostatic changes prior to discharge.  All patients receiving any meds need a telemetry strip pre and post in the chart along with BP on the strip.  Important: if the patient seems anxious consider giving 0.5-2mg of versed. Make sure that they have someone to drive them home.  Attach leads; leads should not overlap or dangle  Nitro spray 1/150 gr. sl. (give to everyone except bypass pts, atrial fibrillation, already on NTG, on Viagra, Cialis, or Levitra)  Sedation: calm soothing compassionate techs! Scanning—Visipaque 320 mg only!!!
 AP – Lat scouts  Breath-hold non-contrast, non-gated CT through entire chest (images reconstructed using lung kernel and sent directly to PACS and to workstation  Low ma breath-held non-contrast from arch to diaphragm  Arm position: Left arm — 10 o'clock, Right arm — 2 o'clock  Manual timing bolus:  Select level of left main coronary artery  Breath hold instructions  20 cc I @ 5.5cc/s followed by 20 cc saline @ 5.5cc/s  Timing bolus at the aortic root (1 image every 2 seconds)  ROI (@ left sinus of valsalva)  Calculate circulation time o There should always be a peak; repeat timing bolus if no peak (may need to change arm position) o Peak is determined by counting the number of "tick-marks" AFTER the 1st zero tick-mark and multiplying by 2 o For VCT: circ time = peak + 11 sec (minimum 22 sec)
5. Coronary
 Non-dual phase  scan FOV: 25 cm  0.625 mm, 120 kVp, 450-800 mA, Gantry speed 0.35 o thin patient: 450 mA o average patient: 650 mA o large patient: 800 mA Heart rate
Snapshot
30-40 Segment 0.16 41-49 Segment 0.18
50-57 Segment 0.20 58-65 Segment 0.22
66-74 Segment 0.24 75-85 Burst 0.20
At TMH, if HR < 65 bpm, then snapshot pulse. 6.  Send 1 reconstructed phases to PACS (75%) at 0.625mm  Send to workstation: o 6 phases: 40%, 45%, 50%, 70%, 75%, 80% at 0.625mm for CAs o dFOV 30 cm at 75% at 0.625mm for PE o 10 phases (0-90%, by 10%) at 2.5mm for function Report content: See worksheet

CT Guided Interventional Procedures

The residents and fellows are responsible for performing interventional procedures in
Ultrasound and CT. Interventional procedures include lung, abdominal, and bone
biopsies, abscess drainages and tumor ablations. General guidelines for performing
procedures follows. We require referring physicians call directly to book procedures so
there is accurate transmission of clinical information. Procedure booking sheets (see end
of this document) should be filled out for all patients when taking the request, and the
person filling out the sheet should print their name legibly. First year residents should
not book procedures. RIH films can be reviewed on PACs and RIMI and Shields exams
can now be accessed via the web on a computer in CT. If the images are from outside,
have the CT secretary call that institution to fax the report at the time of the booking.
Outside films reviewed for upcoming cases are kept in the biopsy bin area in CT and
ultrasound. The plan for the procedure (patient position, side of lesion, area to be
scanned and can be entered onto the new procedure sheet. When the procedure sheet is
completed, it is brought to the CT secretary who then books the case and can call either
the patient of the booking doctor's office with the time. Patient procedure information
sheets are kept in referring physicians offices and should be given to the patient so they
know what to expect in advance. If the referring doctor is seeing the patient in his/her
office, they can be given a patient information sheet at the time of the booking.
Two days before the procedure, the secretary in the radiology recovery room calls all
patients at home to confirm the date and time of their exam to minimize no-shows.
On the evening before the procedure, the fellow and resident should review upcoming
cases for the following day to assure that all films and laboratories are in order. If the
relevant films are not present, they can be retrieved or restored. Good residents will look
at all procedures for the upcoming week to know what is happening, rather than have a
"surprise" each morning at 7:30.
On the morning of the procedure, the cases will be reviewed with the attending to decide
the appropriate approach to a lesion. The plan for the procedure (patient position, side of
lesion, area to be scanned and collimation) should then be entered into the biopsy book
which is kept near the interventional CT console. This information should then be
reviewed with the charge technologist so s/he can plan the day. When the patient arrives
in the CT section, the secretary will stamp a procedure packet and the resident/ fellow
will obtain informed consent from the patient. Informed consent includes 1) an
explanation of the procedure, 2) expected benefits of the procedure, 3) risks of the
procedure and 4) alternatives to the procedure. These all need to be documented. Pre-
procedure assessments should be completed by the senior resident or fellow and the
appropriate documentation completed in the Radiology holding area before the
procedure. That assessment should include review of the indications for the procedure,
relevant blood work and a brief physical exam.
All procedures are performed with the attending present. After the procedure,
outpatients are observed in the holding area and inpatients are returned to the floor. A
procedure note should be left in the chart.
The format for a radiology procedure note should be as follows:
Date:
Radiology
Procedure

Procedure:
Operators:
Medications:
Findings:
Complications:

Orders for monitoring of vital signs and catheter irrigation should be entered on inpatient
order sheets. Biopsy specimens for pathology should be hand delivered by the
residents/fellow to the surgical Pathology Department which is located on the 3d floor of
the bridge building (accessed from the first floor by the ER.) Cytology specimens
should be hand delivered to the cytology department (APC 12th floor.) Specimens for
microbiology should be placed in a sterilized red top tube. This tube can be used for
aerobic cultures, anaerobic cultures and gram stains. Blood culture bottles should not
routinely be used for cultures of aspiration specimens.
Dictations of procedures should include a brief history and indication for the procedure,
the findings on the localizing CT images, the type and amount of anesthesia used and
note of the follow-up period in the radiology holding area. In addition the dictation
should include that the patient was discharged home in the care of his/her wife, family
member etc with printed discharge instructions. Each procedure CT should include a
brief diagnostic portion of the exam with imaging findings. The size and number of
lesions, the type and gauge of needle (or catheter) and number of passes made should be
included in the dictation. The resident should dictate that the attending radiologist was
present during the entire procedure for all interventional cases. All interventional
procedure are dictated at the conclusion of the procedure, these should never be dictated
on the following day. There is an interventional database sheet (see end of this
document)which should be filled out for every CT guided procedure and placed in
the green interventional database binder kept in the interpretation room.

Pre-operative blood work is not necessary or essential in most cases. A routine bleeding history should be obtained from the referring physician and from the patient. Has the patient had any difficulty with bleeding in the past, with dental extractions or prior surgery? If the patient is on any anticoagulants or drugs which could effect coagulation, this should be noted. When blood work is deemed necessary because of an underlying bleeding history or drug history, baseline INR and platelet count should be obtained. Patients with a history suggesting the potential for coagulopathy such as those with liver disease, sepsis, or poor nutritional status should be screened. The department policy on use of anticoagulants and indications for transfusion have recently been modified and are outlined below Guidelines for Hematologic Values and Medication Usage Prior to Invasive Diagnostic Procedures


Procedure
Paracentesis 20-24 Liver, Renal or Order 4 hrs before procedure other CNS Puncture Order 4 hrs before procedure Aspirin (Excedrin, Bufferin) should be withheld for 36 hours before the procedure (not 7 days) NSAIDs (Advil, Motrin, Ibuprofen, Naprosyn, Aleve, Indomethacin) should be withheld for 24 hours before the procedure ADP receptor antagonists (clopidogrel or Plavix) should be withheld for 10 days before the procedure Selective Cox 2 inhibitors (Celebrex, Robecoxib) do NOT need to be discontinued before a procedure. In general we do not perform biopsies in patients with <50,000 platelets. Avoid platelet transfusions prophylactically but if there is a bleed in a thrombocytopenic patient, give 5 units of platelets promptly. Joseph Sweeny, M.D. Director of Lifespan Blood bank 6/02 (jm, wm-s) As the regulatory world becomes more complex, we need to fill out several forms when performing interventional procedures in CT and ultrasound. The following is a summary on these procedures from Marie Kelley RN, nursing director of the radiology recovery area: When doing invasive procedures in all areas of diagnostic imaging, the following documentation is required: 1. A pre-procedure note indicating the planned procedure, diagnosis/indication for study, allergies and current meds 2. Patient history 3. Review of systems 4. Physical exam 5. Documentation of pre-procedure "time out" 6. Marking patient on appropriate side of procedure 7. Post procedure note 8. Signed procedure orders 9. Discharge instructions
Pre procedure notes and history and physical must be either documented in the patient's
chart or filled out on page 1 of the "sedation, invasive procedure & monitoring record."
Post procedure notes are either documented in the patient's chart or on page 2 of the
"ambulatory surgery record".
For all procedures or exams requiring sedation the following information must be
documented on the lower portion of page 1 of the "sedation, invasive procedure &
monitoring record."
1. ASA class 2. History of complications with sedation 3. Sedation plan and sedation meds intended 4. Mallampati airway class 5. Verification of NPO status 6. Consent received for administration of sedation 7. Availability of resuscitative equipment Documentation compliance is reported monthly to the DI and RIH QA committees. Dictation of Procedures: The dictation of a CT guided interventional procedures should include the following components, each in separate paragraphs: 1. History and indication for the procedure 2. Informed consent was obtained after all questions were answered 3. Results of the preliminary scan including size, side and location of lesion 4. Description of procedure 5. Amount of medications administered during procedure 6. Time spent in recovery area including results of f/u x-rays if applicable 7. Instruct the patient to call their referring physician in 3-5 days to obtain the results of the procedure 8. Patient sent home in the care of (mother/father daughter etc) with signed discharge instructions and instructions to return to the nearest ER in the event of an emergency Sedation for Procedures: In general, biopsies are performed without conscious sedation. Administration of 1mg Ativan IV is useful to decrease patient anxiety, and due to its safety profile, this medication can be given without the need for dedicated conscious sedation nursing. If a patient is particularly anxious, conscious sedation can be administered. Abscess drainages and tumor ablations are performed using conscious sedation (versed and fentanyl) administered by dedicated nursing personnel under the direction of the attending. For booking general anesthesia cases for pediatric interventional procedures, the referring doctor and or radiologist should contact the Anesthesia Department at 444-5142 or 444-6030. Dr. Andrew Triebwasser is in charge of pediatric anesthesia. An outline of specific CT Guided interventional procedures follows. Biopsies: Biopsy specimens are sent for cytology, pathology or both. Cytologic specimens are placed in blue top containers with that contain cytolyte liquid for specimen preservation. Pathology specimens are placed in white top containers that contain formalin. The specimen sheets and the container holding the specimen itself must be labeled with the site of origin of the sample. For example "right kidney." Pathology samples should be hand delivered to surgical pathology (3d floor, bridge building) and cytology samples delivered to c the cytology laboratory (13th floor APC building) at the end of the procedure.
The Needle types, specimen containers and laboratory for different types of biopsies are
summarized below. (These may vary depending on attending preference.)
Needles, Solutions and Laboratories for Common CT Guided Biopsies

ANATOMIC
REGION
SOLUTION
19-21G Cytolyte Cytology cytometry Pathology Lung Biopsy: CT guided lung biopsies are booked in a standard fashion using the CT booking sheet. It is the responsibility of the fellow and attending performing the procedure to review all relevant films before performing the actual procedure. Occasionally, patients with a lung lesion will have other intra-abdominal lesions such as an adrenal mass that are amenable to image-guided biopsy with fewer complications. In addition, for patients with old films showing a benign lesion which is stable, a biopsy may not be necessary. While the "booking" radiologist will attempt to get as much information as possible, it is the responsibility of the fellow and attending performing the procedure to biopsy the most appropriate area. In general, you should strive to perform lung biopsies in the morning as the patient can be discharged even if a pneumothorax develops if there is adequate observation period in the afternoon. Late lung biopsies in outpatients often require admission to the hospital which could be avoided if the procedure is performed early in the morning. If the patient has a chest tube placed, it is usually a good idea to check the pathology results to confirm a diagnosis has been made before withdrawing the chest tube. If the findings are nondiagnostic, it is best to re-biopsy the patient with a chest tube still in to obtain an adequate sample. In this scenario a "wet-read" can be performed by the pathology service to assure diagnostic material. Management of Pneumothoraces  In general, if the patient develops a pneumothorax before the lung biopsy is completed on the CT table, we will place a chest tube on the CT table and attach it to the pleurevac to reinflate the lung. There is a Pleurevac within the CT suite at all times specifically for this purpose. After the chest tube has been placed, while the patient is on the CT table, the lung biopsy is then performed. The patient is then brought to the recovery room and if there is no persistent air leak, the chest tube may be placed on straight drain and eventually removed in the recovery room and the patient sent home.  The literature suggests that up to 15% of patients will have a delayed pneumothorax. Most of these occur within the first hour and a small percentage can be delayed as much as three or four hours. It is necessary, therefore, that the patient be in the department at least for two hours so the absence of a pneumothorax can be re-documented. If a small pneumothorax is detected on the immediate post biopsy CT images, I obtain a chest x-ray (PA only) immediately after the CT and at two hours. This way, I can compare chest x-ray to chest x-ray to assess for interval change. If the patient is asymptomatic, hemodynamically stable, the pneumothorax is stable and the patient is reliable and lives near Rhode Island Hospital, he may be sent home with instructions to return to the CT area the following morning. The patient should be given a stamped requisition, told to have a chest x-ray performed the following morning in the General Radiology area, and to bring the chest x-ray to the CT suite and contact the responsible fellow. In general, if the patient remains asymptomatic the following day and the pneumothorax is stable, the patient does not need follow-up. Obviously if the pneumothorax is bigger or the patient is symptomatic, then a chest tube should be placed.  For a patient who develops a pneumothorax post-procedure and becomes symptomatic, a chest tube should be placed either in the recovery room or in VIR. If a chest tube is placed in the recovery room, I prefer using a 10 French drainage catheter inserted along the anterior axillary line at the level of the nipples. A chest x-ray should then be performed to assure resolution of the pneumothorax. If the patient is reliable, asymptomatic and there is no air leak, he may be sent home with a Heimlich valve with instructions to return if symptomatic. As stated above, these patient should be given a chest x-ray requisition and instructed to have a chest x-ray performed in the Main Department and to bring the radiograph to the CT suite.  For patients with a pneumothorax who are old, unreliable, live far from the hospital or desire to be admitted, admission is generally performed to the radiology service. We do not admit patients for observation if they do not have a chest tube. Abscess Drainage: Abscess drainages should be performed with antibiotic coverage. If it is desirable to hold antibiotics until a specimen is aspirated, antibiotics should be initiated immediately following the procedure. It is the recommendation of the Infectious Diseases Division that 3 grams of Zosyn (which is a combination of 2 drugs: piperacillin and tazobactam) be given intravenously for broad spectrum coverage of abdominal abscess drainages. Piperacillin is a penicillin-type antibiotic that works by stopping the growth of bacteria. Tazobactam is an enzyme inhibitor (beta-lactamase inhibitor) that helps the piperacillin work better. Alternatively, 1 gram of Ancef and 80 mg of Gentamicin may be given intravenously at the time of procedure. Outpatients undergoing an abscess drainage generally should be admitted for overnight observation as all patients have a transient bacteremia from the procedure and may have an episode of hypotension. Inpatients and outpatients who have tubes placed in CT/US are followed by the residents, fellows and attendings in the CT /US area. A bulletin board in the CT/US area has a list of patient name, location, tube type, date of tube, referring MD and plan. When a procedure is done, the patient data is entered on the bulletin board by the resident/fellow who performed the procedure. In addition, the patient should be entered into the "Body Tube" folder in the Body Worklist of PACs for review on a daily basis. CT Guided Tumor Ablation: We are one of the busiest image guided tumor ablation services in the world. The interventional tumor ablation service is administered by Derek Tessier NP and by Amy Doorley NP. All patients are seen in advance of the procedure in clinical consultation by either Dr Dupuy, Mayo-Smith, Beland or Haas. Dictations of these consults are available on Lifelinks and should be read by the residents/fellow in advance of the procedure. All patients have the procedure performed with conscious sedation and antibiotics are not routinely administered. Tumor ablation is routinely an outpatient procedure. We perform Percutaneous radiofrequency (RF), cryo and microwave ablations. The modality used depends on tumor size, location and physician preference. Derek Tessier has outlined the general procedure to be followed below: 1. Booking RF/Ablation procedures a. Initial intake by Nurse Practitioner via referring physician or attending radiologist b. Consultation booked through tumor ablation services (Secretary: Robin Holley 444-5707, Derek Tessier, NP 350-4205, Amy Doorley, Nurse Practitioner 350-5910).  Prior to consult, MD/Nurse Practitioner orders imaging as indicated. Patient seen in consultation by MD/Nurse Practitioner. c. Nurse Practitioner books biopsy and/or ablation.  Appropriate testing ordered by Nurse Practitioner (labs, EKG, medication adjustments, etc.) d. Nurse Practitioner will coordinate with anesthesia as indicated. e. Radiology resident and Radiology Recovery Room will be provided with patient H&P and lab work attached to procedure booking sheet. 2. Date of procedure: Nurse Practitioner will consent patient prior to ablation, manage, discharge patient post-ablation, and coordinate follow-up visit/imaging. 3. Admission of Ablation Patients a. Admitting to Observation **  Admit under radiology attending through radiology recovery room. Admitting orders will be submitted by radiology resident/fellow who performed ablation procedure. The following day, Nurse Practitioner will discharge patient from hospital. Radiology resident/fellow will be responsible for discharging patient in POM and completing continuing care form with assistance from Nurse Practitioner. b. Admitting under Teaching Service (Med onc/surgery/medicine)  Nurse Practitioner/resident will contact referring physician who has admitting privileges to Rhode Island Hospital. Patient will be admitted under their service. Radiology will act as consulting specialty. c. Admitting under Non-Admitting physician  Nurse Practitioner will determine whether patient is Coastal Medicine by contacting patient PCP office.  Nurse Practitioner will determine whether patient is IMIS/Hospitalist service by either contacting PCP office or contacting hospital operator.  Radiology will act as consulting specialty. d. Admitting patient from out of network referring physician  Coordinate admission with Medical Admitting resident (350-0113) and/or Medical Consult resident (350-2365), who will evaluate patient in Radiology Recovery Room and admit to teaching services.  Radiology will act as consulting specialty.  Nurse Practitioner will contact referring physician to update on current clinical situation/admission. 4. Ablation patient should appear on radiology "Tube Board" for inpatient rounding ** In cases of ablation patients, where a VIR resident has performed the procedure, the VIR on-call resident should be contacted. ** Cases performed by radiology residents during the daytime should be addressed to the night float short and long resident. Include a note for nursing to contact 4-4123(CT) until 10pm and 4-2727 (ER) after 10pm with acute issues. The resident who performed the procedure should "sign-out" the procedure to the NFS resident at 5pm. Post Procedure Observation Patients who have undergone Image Guided Intervention: Patients are observed in the radiology holding area or on the floor for inpatients. For inpatients, follow-up orders for vital sign monitoring and catheter irrigation should be made. A form regarding the history, physical, procedure and observation care should be filled out on each patient. A pulse oximeter should be utilized whenever conscious sedation is given and vital signs recorded. The hospital mandate for conscious sedation does indicate that patients must have basic monitoring with pulse oximeter if they are medicated with intravenous sedation. Discharge of Patient: All patients undergoing a CT guided procedure should be discharged home with another person to care for them overnight. Patients who have undergone a biopsy are told to contact their referring physician for the results of their biopsy. Following conscious sedation the patient must be alert and awake prior to discharge. Type and amount of sedation administered should be dictated in all interventional cases. A discharge form is available in the department that should be given to each patient documenting the instructions you have given them. The Interventional Radiology nurse calls each patient the next day and verifies that the patient is well. Rounding on Inpatients Treated by CT Radiology: Inpatients and outpatients who have tubes placed in CT/US are followed by the residents, fellows and attendings in the CT /US area. A bulletin board in the CT/US area has a list of patient name, location, tube type, date of tube, referring MD and plan. When a procedure is done, the patient data is entered on the bulletin board by the resident/fellow who performed the procedure. Each morning a resident and or fellow rounds on all patients and gather information on 1.
overall patient status, 2. fever 3. white count, 4. tube drainage and 5. Irrigation.
Residents and fellows will irrigate the tubes on the floor themselves if there is not
drainage. A radiology progress note should be written in the chart. At 8 in the morning,
we will have "tube rounds" with the residents, fellows and either the CT or US attending
to decide on a plan. The person coordinating who will see each patient is the CT
fellow/senior resident. Who sees which patient should be set up the afternoon before.
Decisions on patient management, tube pulling, flushing, changing etc. will be made
during tube rounds and communicated in the chart and with the appropriate referring
service. In addition, the patient should be entered into the "Body Tube" folder in the
Body Worklist of PACs for review on a daily basis.
Needlestick injuries:
Should the resident suffer from a needlestick injury, s/he should be evaluated at employee
health at Rhode Island Hospital.

Admitting Patients

Patients admitted for overnight observation can be admitted to the Radiology service.
Unstable patients with complex medical patients should be admitted to the medical
service. It is critical to get the bed assigned early in the day, so that the patient does not
remain in the radiology recovery room after 5 p.m. It is responsibility of the fellow/ resident who did the procedure to write the admit note and admitting orders. Tips on how to expedite an admission. 1- Do it as early in the day as possible. The later you wait, the more painful it is and the longer it takes. 2- DON'T call "admitting". DO call "Bed Control" (x44523) 3- Know the admitting diagnosis 4- Know patient's name, DOB, MR# 5- Know the admitting attending. They can't begin to book a bed without this. 6- If the plan is to discharge the patient the next day, make sure you book an "OBSERVATION BED". This costs a lot less than a "general" bed. You can't make the mistake of booking a general bed and try to change it to observation-----they won't allow it. You can, however go the other way (i.e. change from observation to a general bed.) 7- Make sure an H&P and Ordered are done ASAP. Use "ADCVANDISL:" Admitting Orders using the POM System  Orders are placed using a computerized system called POM – Physician order management system. There is a link on the lifespan intranet home page under the medical section named POM video training tutorial for physicians, which is a useful guide at the beginning of the rotation to learn about the system.  You will need a Lifelinks password. The login ID is the same as the six digit number assigned to you for Radiology dictation system. You will be assigned a password at orientation or you can contact Lifelinks help desk at 46381 to get your password.  After logging in click on Rhode Island hospital, and go to the Nurses station census. Pick up the nurses station that the patient is being admitted to, for e.g. JB 3 for Jane Brown third floor. The patient's name should already be on the list of that station. Double click on the patient's name. By default it opens the last lab result page.  Click on Write orders/ Post procedure transfer orders. Go to order sets and pick up admit/dsch/order. Alternatively go to New orders and pick Admit orders. It gives you various options like- Admit to Dr …., Status observation vs. inpatient. Highlight the option you want by single click on it and hit o.k. tab at the bottom of the screen.  Remember the basic format of writing orders, which should cover the following  Admit to Interventional Radiology, Dr Mayo-Smith (It should be noted that only certain attendings have admitting privileges and you may need to admit a patient under a different attending than the one who performed the procedure; you should notify an attending if you are looking to admit a patient under their name.)  Condition: Good  Activity: ad lib, or ambulate with assistance  Nursing: chest tube to wall suction at 20 mm hg. There is a comment box for each order in which you can put the changes you want like - change chest tube to water seal at 4.00 am following admission. WE have written two macro orders sets for routine chest tube and abscess catheter maintenance on inpatients which are being incorporated into the POM system.  Diet: Liquids and advance as tolerated  Vitals: Routine, or q shift with pulse oximeter  IV: Int after po.  Meds: you can go to new meds order, which gives a list of common meds to search from and includes the doses. There will be a prompt about frequency, if prn then reason for prn etc. After filling all the fields hit o.k. at the bottom. 1. Common PRN medications should include medications for pain, insomnia,  Tests: Go to Radiology and select CXR. Add in comments – CXR on waterseal and call CT section 444-4123 once it is done (you can check it on PACS).  There is a prompt for all these choices and you can select one and further add additional comments as needed.  The majority of these orders are under the:  "Admitting Med Orders:"  "General Med ADM PT1" and "General Med ADM PT2"  "Other Order Sets:"  "RAD SP abscess" or "RAD SP Chest tube"  Additional follow-up labs/imaging should also be considered for the next morning to facilitate timely patient discharge.  Additional instructions should also be included in the admission orders (for nursing) on how to reach radiology housestaff with over night issues. This can be done as a text order. 1. In cases of ablation patients, where an VIR resident has performed the procedure, the VIR on-call resident should be contacted. 2. Cases performed by radiology residents during the daytime should be addressed to the night float short and long resident. Include a note for nursing to contact 4-4123(CT) until 10pm and 4-2727 (ER) after 10pm with acute issues. The resident who performed the procedure should "sign-out" the procedure to the NFS resident at 5pm. After you have put in all the orders, click the Sign orders tab, and put in your password in the space provided. When the patient is DISCHARGED (usually the following day) the resident/fellow should write a brief DISCHARGE NOTE. This is important so that the admitting attending does not get nasty letters from the medical records department about suspension of admitting privileges. Discharge notes are required in all patients who are in the hospital for 48 hours or less. Patients admitted for more than 48 hours require a discharge dictation. The discharge note should be written in the following format and include the following information: FINAL DISCHARGE DIAGNOSIS: Whatever the diagnosis is. Sign and print your name Discharges are initiated though the POM:  "PT Care FNS"  "Admit/Disch/Transfer" Additionally, a patient "Continuation of Care (COC)" must be separately completed. A link to this is provided on the left-hand column of the Lifelinks page once you have selected the specific patient and initiated discharge procedures. You should also verbally communicate your intentions to discharge the patient to the floor nurse to expedite the discharge. Body MR

By David Grand
Welcome to Body MR. MR is a dynamic, exciting modality. The residents and fellows
are critical to the success of our division. The following is intended to serve not only as an introduction to the service but also as a resource for protocoling studies and for basic study interpretation. Please consult it early and often. The utility of MR for evaluation of the chest, abdomen and pelvis has dramatically increased in the past decade due to more powerful scanners with faster gradients, faster pulse sequences and improved coils. Within the abdomen, MR has quickly become the test of choice for the evaluation of focal and geographic liver disease and the biliary tree. It is also used as a problem solving modality for lesions of the kidneys, adrenal glands and more recently the small bowel. With unparalleled soft tissue resolution, MR is the gold-standard imaging exam for evaluation of the female pelvis and is also useful for the staging of pelvic malignancies in either gender. Currently, the Brown MR division has four, 1.5 Tesla MR scanners. RIH Room 1: Siemens Magnetom Vision: Installed in 1995 this is our eldest scanner. This scanner is currently used for neuroimaging only. After all, the brain is RIH Room 2: Siemens Symphony: 444-3931. Installed in 2003, the majority of the body and all of the cardiac imaging is performed on this scanner. RIH Room 3: Siemens Espree: 444–6403. Installed in 2007, and located in the pediatric imaging center in the basement of Hasbro, this scanner is not just for pediatric patients. It is our most recent addition to the department. It is not an "open" magnet, but does feature a wider bore than conventional scanners which is intended to ease claustrophobia. Being the newest of our scanners, this magnet has the most advanced software platform including powerful diffusion weighted sequences and options for respiratory navigation. W + I – Siemens symphony. 274-1122 ext 1875. The identical scanner to room 2 WORKFLOW:
Technologist places paperwork in "MRI to be Paperwork with protocol AND consults protocol book resident/fellow name placed in and protocols study1 "Body MRI Protcoled" Bin Paperwork placed in "Body MRI to be 1 Please do not hesitate to consult attending on service with questions! The astute resident/fellow will notice four bins on the wall of the body reading room (located on the left as one enters). They include: Body MR to be Protocoled – The technologists will place MD orders for MR's in this
bin. These orders require protocols before being performed. (For notes on protocoling studies, see below.) Residents/fellows MUST WRITE THEIR NAMES LEGIBLY FOR ALL STUDIES THEY PROTOCOL. Body MR Protocoled – Orders which have been protocoled should be placed in this bin.
Body MR to be Read – This bin contains completed studies, ready to be read.
Body MR Read – After reading the study, all paperwork should be placed in this bin.
Currently, we must file this paperwork after the study is read. This is of particular importance for patients at risk of developing NSF (nephrogenic systemic fibrosis) for whom we need documentation of the GFR, communication with the referring physician, dose of and type of gadolinium, etc. RAD-Check: All body MR's will be checked by a resident/fellow BEFORE the patient
leaves the table. Please respond to the technologists' request for a rad-check courteously and expeditiously (translation: stop what you're doing and check the study). The goal of the rad-check is to assure that the protocol was performed appropriately and that the images are of diagnostic quality. The resident/fellow should not spend undue time interpreting the study at this point. If images are not of diagnostic quality or if additional sequences are required, please discuss with technologist (and consult with attending). Remember, sequences which require post-processing will not be available for rad-check as the post-processing occurs after the patient is off the table. BODY MR PROTOCOLING AND INTERPRETATION:
MR is fundamentally used as a problem-solving modality. Examinations are therefore targeted to a specific diagnostic problem/lesion. The goal of MR interpretation is to put this diagnostic issue to rest. It is critical that all previous imaging studies as well as laboratory data and clinic notes be thoroughly reviewed before protocoling and interpreting MR studies. It is unacceptable to perform an MR incorrectly because the purpose of the
examination was not known when it was protocoled.
If the purpose of an examination cannot be determined from all available data, the referring clinician should be contacted. When discussing cases with referring physicians, it is imperative to be friendly and to explain that we are contacting them to optimally image their patient with the goal of performing the final study necessary to answer their clinical question. When put this way, clinicians will (almost) always be happy to discuss the case. We can provide the best answer to the clinical question when we have all the data. When we attempt to interpret studies in a vacuum, everyone loses. Within the protocoling book there is an introductory guide for interpretation of MR studies. Please read it carefully before coming on service. This guide is by no means exhaustive, rather it is a jumping-off point for further study. Please do not hesitate to discuss protocoling questions with the attending on service or myself…anytime (David Grand). Cell: 524-0548. IV. CONTRAST USED IN BODY MR:
A, Intravenous Contrasat Agents All intravenous MRI contrast agents available in the US are chelates of gadolinium. They function by increasing the T1-relaxivity of blood and tissue rendering them bright on T1 weighted images. They are typically power-injected and imaging may be performed dynamically, ie in multiple phases. Practically, there are two categories of gadolinium-agents. Extracellular, Non-specific -- These are the most commonly used agents. They are used for all types of MR imaging. Obviously the pharmaceutical companies would disagree, but they are essentially interchangeable. We most commonly use Magnevist. Gadopentetate Dimeglumine (Magnevist) Gadodiamide (Omniscan) Gadoteridol (ProHance) Liver specific – There are currently two agents which are considered liver specific. Multihance (Gd-BOPTA) and Eovist (Gadoxtate Disodium) are taken up by functioning hepatocytes in the liver and have variable biliary excretion, as opposed to the renal only excretion of the non-specific agents. Delayed images of the liver performed with these agents have been shown to be exquisitely sensitive for detection of small lesions against the bright background of the (still) enhancing liver. Perhaps the main value of these agents is in distinguishing FNH (focal nodular hyperplasia) from hepatic adenoma. The imaging features of these two lesions often overlap when using non-specific gadolinium agents. Both are hypervascular on arterial phase imaging and are essentially isointense to liver parenchyma on portal venous and delayed phase imaging. Despite all the textbook chatter regarding central scars in FNH and heterogeneity due to internal blood and fat within adenomas, these features may only be found in 50% of lesions (as is typical of appearances described as "classic"). On delayed images, FNH will retain these liver specific agents and be hyperintense compared to liver whereas adenomas will be isointense. Like most explanations, the following is postulated rather than known, but it makes us feel better and gives us something official sounding to tell the referring clinicians. Both FNH and adenoma have functioning hepatocytes, however whereas FNH has abnormal, blind ending bile ducts, adenomas have no ducts at all. FNH will therefore take up the contrast hoping to excrete it but its ducts are abnormal and the contrast has nowhere to go. Because adenomas have no ducts at all, biliary metabolism is blocked entirely and its hepatocytes will neither take up nor excrete the contrast. Because these agents are excreted through the biliary tree (in addition to renal excretion) it is possible to use them to make very pretty T1-weighted MRCPs. While interesting in principle, this technique has not proven particularly useful. The dosing of intravenous contrast agents should be determined by weight. A standard or "single" dose of a conventional, nonspecific gadolinium agent is 0.1 mmol/kg.2 A "double" dose is 0.2 mmol/kg. Traditionally, MRA's and cardiac exams are performed with a double dose, although this is changing with better scanners, better contrast agents, and fear of NSF (nephrogenic systemic fibrosis – more below). At the time of writing, the optimal dose of Eovist (Gadoxtate Disodium) is controversial. We use 10 cc regardless of weight (it comes in a 10 cc vial). Intravenous contrast agents are typically power-injected at 2 cc/sec followed by a 20 cc saline "chaser" to flush the contrast from the tubing into the vasculature. B. Oral Contrast Agents Oral contrast is currently used for two indications. First, we use a barium sulfate suspension (0.1% w/v, VoLumen) which is a low-concentration barium and sorbitol solution to distend the small bowel for MR enterography examinations. Small bowel distension is critical to the utility of these studies, and because of the sorbitol this contrast agent cannot be absorbed in the bowel. Secondly, we routinely use ferumoxsil (GastroMARK) for MRCP's. GastroMARK is a suspension of iron-oxide which is dark on both T1 and T2-weighted images. This helps to eliminate fluid signal within the duodenum which could otherwise obscure the ductal anatomy on MRCP images (which are heavily T2-weighted). MR Contrast Use (Gadolinium) in Patients with Renal Dysfunction
During my MR fellowship, elevated creatinine (poor renal function) was probably the single most common indication for performing MRI. Times have changed. Recently, a small number of patients with decreased renal function who received gadolinium for an MRI exam acquired a potentially fatal disease, Nephrogenic Systemic Fibrosis. Although 2 The manufacturers have actually done us a favor here. The concentrations of all listed IV contrast agents except Eovist (Gadoxtate Disodium) are such that the standard dose of 0.1 mmol/kg is roughly equal in cc's to the patient's weight in pounds divided by ten. Hence, a single dose of gadolinium for a 150 lb person is 15 cc's. A double dose would be 30 cc's. gadolinium contrast agents have always been thought to be innocuous, the gadolinium ion itself is known to be quite toxic. By binding it into a larger molecule, it is rendered inert. Remember that all nor nearly all of the excretion of these agents is renal. It is thought that patients' with poor renal function may not excrete all of the contrast agent before the gadolinium ion manages to dissociate itself from its larger molecule. It is then free to wreak havoc.3 Recent studies have linked a serious group of diseases known a Nephrogenic Systemic Fibrosis/Nephrogenic Fibrosing Dermopathy (NSF/NFD) to the administration of gadolinium-based contrast agents in dialysis-dependent patients and those with severe renal failure. Use of gadolinium in patients with moderately reduced renal function has also recently been cautioned by the FDA. Gadolinium-chelate compounds, may pose a risk for NSF/NFD in patients with moderate renal failure, estimated Glomerular Filtration Rate (eGFR) of 30-60ml/min, and therefore should only be used if necessary for diagnosis, limiting dose to minimum required. Recent FDA advisory states that "the risk, if any, for developing NSF among patients with mild to moderate renal insufficiency or normal renal function is unknown". In patients with severe renal failure (eGFR < 30) exposure to gadolinium containing contrast agents increases the risk for NSF (estimated to be 3-7%). Significant risk is also present for patients with acute renal insufficiency of any severity, or renal insufficiency due to hepato-renal syndrome. A recent study identified a small group of patients with eGFR between 30-40ml/min who developed NSF. These patients were later found to have had undetected ATN at the time of Gd administration. Extreme caution should be exercised in all patients with acute renal insufficiency related to recent major surgery/vascular procedures, sepsis or in the peri-transplantation period. Acidosis and elevated serum Ca, Fe, P have also been associated with increased risk. High dose erythropoietin therapy and immunosuppression may be linked to NSF/NFD. 3 This is also why we NEVER, NEVER, NEVER give gadolinium to a pregnant patient. The contrast agent can diffuse into the amniotic fluid and stay there – with plenty of time for the gadolinium ions to disassociate and cause trouble. Among the factors that may increase the risk for NSF are repeated or higher than recommended doses of gadolinium containing contrast agents. Although this is a rapidly evolving topic these guidelines provide an initial framework for the care of patients who may be at risk for gadolinium associated NSF/NFD. OUR CURRENT GUIDELINES: Guidelines are established to define procedures which reflect appropriate care practices for providing imaging and interventional procedures. These guidelines shall be used routinely; however, actual practice may be altered to fit specific patient conditions which may be recognized. Altered practices from these guidelines must first be approved by a Radiologist as he/she evaluates the patient's condition and clinical circumstances against the imaging or intervention services being requested. Procedure: Guidelines for Patient Screening:
Adult Patient screening shall be performed for assessment of moderate or severe renal disease by obtaining serum creatinine (obtained within 6 weeks of the examination)
and calculating eGFR (using the MDRD Study equation Modification of Diet in Renal Disease: located at http://mdrd.com or eGFR calculators available at each MR unit. For patients under 18 years of age the Schwartz Formula should be used to calculate eGFR: located at http://nephron.com/cgi-bin/peds_nic.cgi.), when any of the following risk
factors are present: Inpatient/ER Patient: a. Age greater than 60 b. Known or suspected renal disease / acute tubular necrosis c. Diabetes/Hypertension d. Hepato-Renal Syndrome/Liver Transplant Recipient/ other recent transplant e. Any recent major surgery/vascular procedures/sepsis. a. Known or suspected renal disease b. Diabetes/Hypertension c. Liver transplant recipient/ other recent transplant Guidelines for Performance of Gadolinium Enhanced MR Examinations based on patient risk category and examination type: a. No risk factors/single dose study- single dose gadolinium agent (Magnevist/Multihance) b. No risk factors/Multi dose study- Maximum double dose Multihance. c. Risk factors HTN or Diabetes/No Creatinine Available- Contrast may be administered per above guidelines if eGFR is greater than 60ml/min calculated from creatinine obtained within one year if the patient is followed by a physician for this condition and reports no recent change in condition, reason for exam does not include assessment of urinary tract, and there are no additional risk factors. Patients who have had a recent CECT scan must have documentation of stable post CT renal function. If creatinine cannot be obtained then non-contrast examination performed when appropriate. If gadolinium is recommended following Radiologist review of non-contrast study, referring physician is notified. If upon discussion with referring physician the decision is made to proceed with CE portion of MR examination, creatinine must be obtained, and reported to MR at the time of limited CE examination scheduling. If eGFR >60, proceed with examination as described above, if <60 see below. d. eGFR less than 60ml/min, greater than 30ml/min (moderate renal failure)- Non-contrast examination should be performed. If this is not diagnostic or based on clinical history there is a diagnostic imperative for gadolinium administration (i.e. rule out metastatic breast cancer for pre treatment staging) and gadolinium is indicated, consideration of risk benefit analysis documented by Radiologist in the patient record. Radiologist prescription of amount & type of gadolinium given must be recorded. Limited Gadolinium dose is recommended which should be tailored to the specific examination requirement. Multihance is recommended. Multihance dose should be tailored to limit total gadolinium exposure and take advantage of the increased T1 relaxivity of this agent to reduce overall contrast volume. (i.e. double dose exams may be performed using single dose Multihance, and single dose studies may at times be performed with a reduced dose). eGFR=30-40, creatinine obtained within 24 hrs, ensure no risk for ATN (stable Cr), Assess prior Gadolinium administration (cumulative dose over preceeding year may present risk) or recent CT contrast exposure (ATN risk- stable post CT Cr must be recorded), no additional risk factors for NSF. Consult with primary physician. If Gd required recommend ½ dose eGFR=40-50, creatinine obtained within 6 weeks, assess prior Gadolinium administration (cumulative dose over preceeding year may present risk) or recent CT contrast exposure (ATN risk-stable post CT Cr must be recorded), no additional risk factors for NSF.If Gd required recommend minimum necessary Multihance dose, not to exceed single dose. eGFR=50-60, creatinine obtained within 6 weeks, Assess prior gadolinium administration (cumulative dose over preceeding year may present risk) or recent CT contrast exposure (ATN risk-stable post CT Cr must be recorded), no additional risk factors for NSF. If Gd required recommend single dose e. eGFR less than or equal to 30ml/min (severe renal failure) or acute renal insufficiency of any severity due to the hepato-renal syndrome or in the perioperative transplantation period, recent major surgery, sepsis, major vascular procedures. Prudent not to administer gadolinium compound if previous gadolinium administration within preceeding year. Non-contrast examination should be performed. If this is not diagnostic, Radiologist review of gadolinium indication is required in consultation with the Referring Physician and Nephrologist. If gadolinium is indicated, consultation and
consideration of alternative examinations should be documented in the patient record. Patient/Guardian informed consent should be obtained with estimated risk clearly stated (estimated risk of NSF/NFD 3-7%). Limit dose necessary for MR procedure, half dose Multihance is If patient receives hemodialysis, follow-up dialysis treatment must be performed within 2 hours and again within 24 hours of gadolinium administration. It is unknown however if hemodialysis prevents NSF. Peritoneal Dialysis is not believed to be effective in clearing gadolinium. Patients undergoing peritoneal dialysis may not receive gadolinium unless Nephrology is consulted and hemodialysis is planned. Patients receiving gadolinium who are at risk for NSF require clinical follow-up and long term monitoring for the disease. Fundamentally, like everything else we do in medicine, this is a calculation of
risk/benefit. We tend to lose sight of this calculation, inherent in all medical tests and
procedures, because radiology tests and procedures are typically quite safe. However,
there is risk to the patient in everything we do, and our willingness to perform a
test/procedure implies that after careful consideration we believe the benefit of the
test/procedure to outweigh the risk. It is important to remember that to date not a single
person with normal renal function has acquired NSF. NSF has certainly increased the
risk in the risk/benefit equation, however we should our judgment in addition to the
above guidelines to calculate the risk/benefit ratio for each patient at risk.


CT EDUCATIONAL GOALS AND OBJECTIVES

First Year Residents:

Medical Knowledge
1.
Describe the basic physics of computerized tomography Describe Hounsfield units, window and level settings Describe proper CT protocols for specific disease processes Describe dynamic vs. equilibrium phase imaging and differentiate between these entities Describe normal thoracic parenchymal, mediastinal and vascular anatomy Describe normal abdominal and pelvic anatomy State indications for aortic dissection CT and the protocol to be followed with this examination Describe the differences between axial CT, helical CT, and MDCT Describe indications for body MR exams Patient Care: 1. Become familiar with CT protocols Be able to manage contrast reactions Practice-based Learning and Improvement: 1. Identify, rectify and learn from personal errors Incorporate feedback into improved performance Efficiently use electronic resources (Lifelinks) to access information Schedule exams appropriately Communication and Interpersonal Skills: 1. Appropriately communicate and document in the patient record urgent or unexpected radiologic findings Produce radiologic reports that are accurate, concise and grammatically correct Communicate effectively with all members of the health care team Professionalism: 1. Demonstrate respect for patients and all members of the health care team Serve as a role model for medical students Respect patient confidentiality Present oneself as a professional in appearance and communication. System-based Practice: 1. Demonstrate knowledge of how radiologic information is integrated with the other parts of the health care system in the treatment of the patient Demonstrate knowledge of ACR standards and appropriateness criteria Demonstrate knowledge of cost-effective imaging practices
Second Year Residents:

Medical Knowledge
1.
Describe the basic physics of computerized tomography Describe Hounsfield units, window and level settings Describe proper CT protocols for specific disease processes Describe dynamic vs. equilibrium phase imaging and differentiate between these entities Describe normal thoracic parenchymal, mediastinal and vascular anatomy Describe normal abdominal and pelvic anatomy State indications for aortic dissection CT and the protocol to be followed with this examination Describe the differences between axial CT, helical CT, and MDCT Describe indications for body MR exams Describe Body MR protocols and indications for intravenous MR contrast Patient Care: 1. Become familiar with body CT and MR protocols for patients Be able to manage contrast reactions Practice-based Learning and Improvement: 1. Identify, rectify and learn from personal errors Incorporate feedback into improved performance Efficiently use electronic resources (Lifelinks) to access information Schedule exams appropriately Communication and Interpersonal Skills: 1. Appropriately obtain informed consent for CT guided interventional procedures Appropriately communicate and document in the patient record urgent or unexpected radiologic findings Produce radiologic reports that are accurate, concise and grammatically correct Communicate effectively with all members of the health care team Professionalism: 1. Demonstrate respect for patients and all members of the health care team Serve as a role model for medical students Respect patient confidentiality Present oneself as a professional in appearance and communication. System-based Practice: 1. Demonstrate knowledge of how radiologic information is integrated with the other parts of the health care system in the treatment of the patient Demonstrate knowledge of ACR standards and appropriateness criteria Demonstrate knowledge of cost-effective imaging practices
Third Year Residents:

Medical Knowledge:
1.
Respond logically and with competence as a Body Radiology consultant. Prescribe and interpret CT/MR exams in the chest and abdomen. Describe radiation dose reduction principles in CT Describe volume, doses and administration rates of contrast for CT examinations. Provide a differential diagnosis for a) thoracic, abdominal and pelvic pathology Indications for CT-guided chest, abdominal and pelvic CT interventions Indication and techniques of CT-guided abscess drainages and biopsies. Describe Body MR protocols and indications for intravenous MR contrast Orient and supervise the proper imaging investigation of a patient or of a specific disease. Patient Care: 1. Develop a management plan based upon CT, US and or MR findings and clinical information. 2. Demonstrate proper technique in planning and performing CT procedures Know the appropriate indications for body CT and MR examinations and alternatives depending on the suspected diagnosis. Appropriately protocol CT and body MR cases based upon the indication for the examination Minimize adverse reactions to iodinated contrast through appropriate patient selection and medication. Practice-based Learning and Improvement: 1. Identify, rectify and learn from personal errors Incorporate feedback into improved performance Efficiently use electronic resources (Lifelinks) to access information procedures appropriately Use appropriate protocols and techniques for radiation dose reduction in CT Communication and Interpersonal Skills: 1. Appropriately obtain informed consent Appropriately communicate and document in the patient record urgent or unexpected radiologic findings Produce radiologic reports that are accurate, concise and grammatically correct Effectively teach junior residents and medical students Communicate effectively with all members of the health care team Professionalism: 1. Demonstrate respect for patients and all members of the health care team Serve as a role model for junior residents and medical students Respect patient confidentiality Present oneself as a professional in appearance and communication. Demonstrate a responsible work ethic with regard to work assignments Systems-based Practice: 1. Demonstrate knowledge of how radiologic information is integrated with the other parts of the health care system in the treatment of the patient Demonstrate knowledge of ACR practice guidelines for CT examinations Demonstrate knowledge of cost-effective imaging practices Understand treatment implicated by findings on CT or MR (e.g. what is the next treatment that should occur based on the CT/MR findings).
Fourth Year Residents:

Medical Knowledge:
1.
Respond logically and with competence as a Body Radiology consultant. Prescribe and interpret CT/MR exams in the chest and abdomen. Describe radiation dose reduction principles in CT and the ALARA (as low as reasonably achievable principles) Describe volume, doses and administration rates of contrast for CT examinations. Provide a differential diagnosis for a) thoracic, abdominal and pelvic pathology Indications for CT-guided chest, abdominal and pelvic CT interventions Indication and techniques of CT-guided abscess drainages and biopsies. Indications for image guided tumor ablation. Describe Body MR protocols and indications for intravenous MR contrast Orient and supervise the proper imaging investigation of a patient or of a specific disease. Patient Care: 1. Develop a management plan based upon CT, US and or MR findings and clinical information. 2. Demonstrate proper technique in planning and performing CT procedures Know the appropriate indications for body CT and MR examinations and alternatives depending on the suspected diagnosis. Appropriately protocol CT and body MR cases based upon the indication for the examination Minimize adverse reactions to iodinated contrast through appropriate patient selection and medication. Practice-based Learning and Improvement: 1. Identify, rectify and learn from personal errors Incorporate feedback into improved performance Efficiently use electronic resources (Lifelinks) to access information procedures appropriately Use appropriate protocols and techniques for radiation dose reduction in CT Communication and Interpersonal Skills: 1. Appropriately obtain informed consent Appropriately communicate and document in the patient record urgent or unexpected radiologic findings Produce radiologic reports that are accurate, concise and grammatically correct Effectively teach junior residents and medical students Communicate effectively with all members of the health care team Professionalism: 1. Demonstrate respect for patients and all members of the health care team Serve as a role model for junior residents and medical students Respect patient confidentiality Present oneself as a professional in appearance and communication. Demonstrate a responsible work ethic with regard to work assignments Systems-based Practice: 1. Demonstrate knowledge of how radiologic information is integrated with the other parts of the health care system in the treatment of the patient Demonstrate knowledge of ACR practice guidelines for CT examinations Demonstrate knowledge of cost-effective imaging practices Understand treatment implicated by findings on CT or MR (e.g. what is the next treatment that should occur based on the CT/MR findings). EVALUATION of RESIDENTS on BODY ROTATION
These are the evaluation mechanisms used to evaluate the resident and determine that the program goals and objectives are met. Evaluation Forms Monthly rotation evaluation by faculty Evaluation by CT technology staff. Exams ACR inservice exam Mock Oral Board exam Portfolio Procedure Logs The residents will also be evaluated on: 1. Attendance during Body rotation. Efficiency during Body rotation. Knowledge of Body protocols. Knowledge of relevant anatomy, physiology and pathology. Knowledge of proper prescription of CT/MR examinations. Ability to provide a reasonable differential diagnosis for a CT/MR imaging finding and suggest the next most appropriate step in the work-up of the patient. Ability to appropriately book and perform CT-guided interventions. Efficiency in dictating studies. Quality of dictations. 10. Interactions referring physicians. Affability with coworkers, technologists, secretaries, nursing staff and radiology support staff. IV. CT REFERENCES

1) Fundamentals of Body CT by W. Richard Richard Webb, William E. Brant, William
E. Brant, Clyde A. Helms (Great for 1st years - quick intro to CT) 3rd Edition, Saunders,
October 2005
2) Fundamentals of Diagnostic Radiology by William E. Brant, Clyde A. Helms
Lippincott Williams & Wilkins, June 2006
3) Body MRI by Evan S. Siegelman Saunders, December 2004
4) The Radiology of Emergency Medicine by John H Harris and William H Harris
Lippincott Williams & Wilkins, December 1999
5) Thoracic Radiology: the Requisites by Theresa C. McLoud Mosby, August 1999
6) Teaching Atlas Of Chest Imaging by Mark Parker, Melissa De Christenson, and
Gerald Abbott Thieme, December 2005
7) Thoracic Imaging : Case Review Series by Phillip M. Boiselle, Theresa C. McLoud
Mosby, January 2001
8) Genitourinary Imaging : Case Review Series by Ronald J. Zagoria, William W. Mayo-
Smith, Julia R. Fielding, Mosby, September 2006
9) Gastrointestinal Imaging : Case Review Series by Robert D. Halpert Mosby, 2007
10) Diagnostic and Surgical Imaging Anatomy: Chest, Abdomen, Pelvis: by Michael P
Federle, Melissa L Rosado-de-Christenson, Paula J Woodward, Gerald F Abbott and
Akram M Shaaban. Lippincott, Williams & Wilkins, December 2006.
11) Diagnostic Imaging: Abdomen. by Michael Federle, R. Brooke Jeffrey, Venkat
Sridhar Anne. 2004
Reference to various anatomy texts and atlases will often be necessary.
Appendix:
 CT Procedure Booking Sheet  CT Database Entry Sheet  Post Procedure Discharge Sheet  CT Division central line policy  Pregnant Patient Consent form CT/US Imaging Interventional Procedure
Booking/Order Sheet
Rhode Island Hospital, Department of Diagnostic Imaging 6-06
Patient Name:
Patient Location:
Patient Home/Cell #:
Ordering Physician:
MD Page/Back line #:
Brief History:
Procedure Requested:

Lab test desired on sample / Special instructions:

Can patient give Consent?
Yes No If not, who will give consent? Translator necessary?

Diagnostic Exam From?
RIH RIMI (fax report) Shields (fax report)
W&I (fax report) Outside (fax

Is patient taking anticoagulants/Aspirin/NSAID? No
Yes, what medication?: Hold Medications as follows: Aspirin 36 hrs; NSAIDS 24 hrs; Enoxaprin (lovenox) 12 hrs; Plavix (clopidrogel) 7 days If yes, who will tell patient to stop?
Lab Work:
Referring Physician to do Last resort: to be done on admission (have patient arrive 2 hours
early)
PT/PTT:

Patient Position for Procedure:
Decubitus Side

For Tumor Ablation:

Scheduled Date: /

Resident & Attending Approving Procedure:
Today's Date: /
Radiology Procedure Data Sheet Pt. Name: MR #:
Anesthesia: 1. Local 2. Conscious Sedation 3. General
Patient Location: 1. Inpatient 2. Outpatient 3. W&I
Fellow: 1. Caiati 2. Husain 3. Iafrate 4. Singh 5. Resident
Radiologist: 1. Atalay 2. Cronan 3. Dupuy 4.Haas 5. Mayo 6. Murphy 7.Pezz 8. Ridlen
9. Other:
CA History: 1. No known primary 2. Lung 3. Breast 4. Colon 5. Pancreas 6. Cervix 7. Ovarian
8. Endometrial 9. Lymphoma 10. Prostate 11. Renal 12. Other: Procedure DATE: / / _ CT Fluoro time: _ seconds CT Room
time: min
I. BIOPSY
Pre Bx Probability of CA: 0 (defin. not) 1 (prob not) 2 (equivocal) 3 (prob malignant) 4 (defin. malignant)
Biopsy Site: 1. Neck 2. Thyroid 3. Lung 4. Mediastinum 5. Liver 6. Adrenal 7. Renal 8. Pancreas
9. Retroperitoneal Node 10. Spine 11. Pelvic Node 12. Bone 13. Other: _
Lesion Size: <1 cm 1 cm 2 cm 3 cm 4 cm >4 cm
# Lesions Present: 1. 2. 3. 4. >4
Needle Type: 1. Franseen 2. Temno (20/18G) 3. Biopsy Gun (18G) 4. Coax Lung (19/21) 5. Ackerman
(14)
BX Needle Size: 14g 16g 18g 19g 20g 21g 22g Other _
# Passes: 1. 2. 3. 4. >4 Technique: 1. Coaxial 2. Tandem On Site Cytopath: 1. No 2. Yes: + 3. Yes: -
II. DRAINAGE
Procedure type: 1. Aspiration 2. Drainage Technique: 1. Trocar 2. Seldinger
Location: 1. Neck 2. Pleural space 3. Lung 4. Liver 5. Pancreas 6. Spleen 7. Renal
8. Diverticula
9. Pelvis 10. Spine 11. Extremities 12. Other:
Etiology: 1. Postop 2. Diverticula 3. Immunocompromised 4. Other:
_
Catheter Size: 8F 10F 12F 14F 21F Other: _ Number of
Catheters: 1 2 >2 Aspirate Vol #1: _ Vol #2: _ Infection: Yes
No Cavity Collapse: Yes No
III. TUMOR ABLATION (circle type ) 1. RF 2. Cryo 3.
Microwave 4. ETOH
Site: 1. Neck 2. Lung 3. Liver 4. Node 5. Spine 6. Bone 7. Renal 8. Other: _
# Lesions Treated: 1. 2. 3. 4. >4 Max dimension (of each lesion) lesion 1 _ lesion 2. _
Probe Type: 1. Single 2. Triple # of Probes: 1 2 3 4 5 6 >6 Tip Length: 1cm 2cm 2.5 cm.(cluster only) 3cm
# Treatments per lesion: Avg Imped (ohms) _ Avg Current (amps) _ Avg Power (watts) _
Average T max: Average Treatment Time: (min) Thaw Time
(cryo) : _Vol. (etoh) _

IV. OTHER PROCEDURE
Type: -


V. COMPLICATIONS
1. None 2. PTX (no tube) 3. PTX (+tube) 4. Bleed 5. Patient Admitted 6.
Other: _
VI.
COMMENTS: _
_ 7/05
BROWN UNIVERSITY / RHODE ISLAND HOSPITAL
DEPARTMENT OF RADIOLOGY

POST PROCEDURE INFORMATION SHEET

NAME: _ _
DATE:
You have had a needle biopsy/fluid aspiration of your using CT / Ultrasound guidance today. You should resume all of your normal medications after this procedure and you may use acetaminophen (Tylenol) as a pain reliever. You may shower 24 hours after the procedure and resume normal activity tomorrow as pain permits. You should contact your referring doctor for the results of this test. You should have no problems. However, as with any invasive procedure there is always a small risk of complication. If within 24-48 hours you develop increased pain, skin redness, fever or shortness of breath or you have any other concerns, please contact us without delay. Our daytime telephone number is 401-444-8392 (CT) or 401-444-5309 (Ultrasound). Please ask to speak to the radiologist at this number. If any of these symptoms develop after 5 PM you may call the interventional radiologist through the page operator at (401) 444-5611. You may come directly to the emergency room if you feel more immediate treatment is necessary. Please bring this sheet with you as this is important information to provide to the physician on duty. The RIH CT Policy for Contrast Administration and Catheter size/type, (4-07):
Types of intravenous contrast
 Omnipaque 350 will be used on all adult patients needing iv contrast.  Visipaque 320 will be used for patients with decreased renal function. The Radiologist will protocol when a patient will receive Visipaque 320.  Visipaque 320 is also used, by protocol, for ct scans of the heart. (cardiac cta and pulmonary vein mapping)  Omnipaque 300 will be used on all pediatric patients needing iv contrast. The contrast volume for pediatric patients is determined by 1cc of iv contrast per pound of patient's body weight for patients less than 100 pounds. Pediatric patients weighing over 100 pounds will receive the adult contrast volume of Omnipaque 300. CT Scan Peripheral IV Access Policy  Omnipaque 300/350 intravenous access requirements: o Injection rate of up to 2.4cc/second: 22 gauge or larger o Injection rate of 2.5cc/sec to 4cc/second: 20 gauge or larger o Injection rate of 4.1cc/sec or greater: 18 gauge or larger  Visipaque 320 intravenous access requirements: o Injection rate of up to 3cc/second: 20 gauge or larger o Injection rate of 3.1cc/sec or greater: 18 gauge or larger CTA Scan Peripheral Intravenous Access Policy  A 20 gauge or larger IV in an antecubital vein is preferred to perform a CTA study. Exceptions can be made at the discretion of the radiologist and technologist if a patient's current iv access can yield a quality study without reducing the injection rate.  The rationale is to prevent extravasation and poor quality exams from inadequate intravenous lines. CT Scan Adult Patient Central Line Policy  It is the policy of the CT department to establish, whenever possible, adequate peripheral iv access. Central lines will be used only when our own peripheral iv access cannot be attained.  If a nurse accompanies the patient, always defer to her/him as to which line to use for an iv contrast injection. There are some lines that cannot be used at all.  If a patient needs to have a port-a-cath accessed and the clinic is unable to do it, then a Radiologist can access the port. Access kits are available in the CT department for this purpose.  All iv contrast injections will be monitored for as long as possible prior to the start of the scan.  If there is any question or concern regarding the use of a central line, consult a Types of Central Lines in Adult Patients at Rhode Island Hospital  Port-a-cath / perm-a-cath / Hickman catheter: These are generally found in the
chest, however there are some versions that are placed in a patient's arm. A Hickman cather is identifiable by it's white color and usually has one or two ports. A port located in the patient's arm cannot be used for an iv contrast power injection. Only hand injections can be used with a port-a-cath, perm-a-cath, or Hickman catheter. Port-a-cath, perm-a-cath, or Hickman catheters cannot be used for CT angiography. Any implanted venous access device on adult patients should be accessed, flushed and deaccessed as described in Rhode Island Hospital Nursing Practice Manual, File K-7. The flush of heparinized saline is 5cc, 100 units/mL.  Swan-Ganz catheter: These are identifiable by their yellow colored sheath. This
catheter can sometimes go into a pulmonary artery. Never use a Swan-Ganz port that goes into a pulmonary artery. This port is identified on its outer tubing by the letters "PA". If iv contrast is injected directly into a pulmonary artery, flash pulmonary edema can occur. Usually, the blue ‘CVP" line can be used for iv contrast injection. When performing routine diagnostic contrast CT scans, an injection rate of 2cc/sec will be used. When performing CT angiography, an injection rate of 3cc/sec will be used.  Triple lumen catheter: These can be located in the neck, chest or groin. They are
identifiable by their three ports on the outer end of the catheter. The colors of the ports are blue, brown, and white. If possible, use a port that is not being used for anything else. When performing routine diagnostic contrast CT scans, an injection rate of 2cc/sec will be used. When performing CT angiography, an injection rate of 3cc/sec will be used.  PICC lines: These can be found in both adult and pediatric patients. They are
located in the patient's arm. PICC lines can never be used for power injection or hand injection. PICC lines are too small and easily ruptured.  Power PICC lines: These can be found in adult patients and are approved for
power injections. These are located in the patient's arm. Power PICC lines have two or three ports. One of the ports has purple tubing with a red end. The purple and red port can be used for CT scans. Power PICC lines can be injected up to a rate of 5cc/sec at a maximum of 300psi. The port for injection is labeled "5ml/sec MAX" directly on the clamp. Prior to and after each contrast power injection, the Power PICC is to be checked for patency via flushing with a 10cc normal saline. Do not proceed with power injection if complete catheter patency cannot be established.  Morpheus CT PICC lines: These can be found in adult patients and are
approved for power injections. These catheters can only be relied upon for CT
studies with an injection rate of up to 4cc/second. Use only warm contrast when
injecting through a Morpheus line. These are located in the patient's arm.
Morpheus CT PICC lines may have a single port or a double port. Angio
Dynamics states Morpheus CT PICC lines can be injected up to a rate of 6cc/sec
at a maximum pressure of 250psi only if the iv contrast is warmed to body
temperature. They also require that the catheter be flushed with heparinized
saline after each use. The port for injection is labeled "6ml/sec" directly on the
tubing. Prior to and after each contrast power injection, the Morpheus CT PICC
is to be checked for patency via flushing with a 10cc normal saline. Do not proceed with power injection if complete catheter patency cannot be established.  Arterial lines (A lines): These can never be used for any form of contrast
CT Scan Pediatric Patient Central Line Policy  It is the policy of the CT department to inject iv contrast through adequate peripheral iv access whenever possible. Central lines will be used only when peripheral iv access cannot be attained.  Pediatric patients 14 years old and up with adult sized central lines, can have
their central lines used as per the adult policy.  Children 14 years old and under should only have central lines used if no peripheral iv access is available. If a central line needs to be used on a pediatric patient in this age category, only hand injections of iv contrast should be performed.  The iv contrast should always be warm whenever performing a hand injection
in an effort to reduce contrast viscosity.  If a nurse accompanies the patient, always defer to her/him as to which line to use for an iv contrast injection. There are some lines that cannot be used at all.  If a patient needs to have a port-a-cath accessed and the clinic is unable to do it, then a Radiologist can access the port. Access kits are available in the CT department for this purpose.  All iv contrast injections will be monitored for as long as possible prior to the start of the scan.  If there is any question or concern regarding the use of a central line, consult a Types of Central Lines in Pediatric Patients at Rhode Island Hospital  Port-a-cath / perm-a-cath / Hickman / Broviac catheter: These are generally
found in the chest, however there are some versions that are placed in a patient's arm. Hickman and Broviac cathers are identifiable by their white color and usually have one or two ports. A port located in the patient's arm cannot be used for an iv contrast power injection. Only hand injections can be used with a port-a-cath, perm-a-cath, Broviac, or Hickman catheter. Port-a-cath, perm-a-cath, Broviac, or Hickman catheters cannot be used for CT angiography.  PICC lines: These can be found in both adult and pediatric patients. They are
located in the patient's arm. PICC lines can never be used for power injection. PICC lines can be used for hand injections of iv contrast on pediatric patients.  There are four other central lines specifically used for pediatric patients:
1. 4 french, 8cm, double lumen. These lines are usually in babies less than 12 2. 4 french, 13cm, double lumen. 3. 5.5 french, 8cm, triple lumen. 4. 5.5 french, 13cm, triple lumen. The four lines above can only have iv contrast hand injected through them. The 5.5 french lines are rated to have a maximum flow of 1300cc of saline/hour. This translates to .36cc of saline/second. Therefore, only hand injections of iv contrast are permitted. Accessing a Central Venous Catheter for Intermittent Infusion (From Rhode Island Hospital Nursing Practice Manual, File C-53)  Perform hand hygiene, using alcohol based gel and hand washing.  Don non-sterile gloves. This is not a sterile procedure.  Wipe the injection cap with alcohol. Cleanse using friction for 1 minute with each of three alcohol wipes. Allow residual alcohol to dry.  Attach a 10 mL syringe of normal saline to the injection cap. Aspirate for blood return and flush.  Connect iv contrast tubing access device to the injection cap.  When the iv contrast injection is completed, disconnect tubing.  Alcohol wipe injection cap, and flush with 10 mL normal saline.  If a flush of heparinized saline is required, the patient's nurse should flush the line with heparin using positive pressure to prevent reflux of blood into the catheter.

Consent for Imaging Studies Using Ionizing Radiation
During Pregnancy

Dr. is requesting the following imaging
referring physician
study which uses radiation to
study to be performed
evaluate . Because you are pregnant, we
would like you to understand what we know about the effects of the imaging study on you and your
baby and need your consent before performing this exam. A patient information sheet that explains
some of the risks from radiation in pregnancy is located on the back of this consent.
The following checked items apply:
 You and your baby will be exposed to low levels of radiation. This imaging study uses low doses of
radiation and the risks from this test are much smaller than the normal risks of pregnancy. This
examination might slightly increase the possibility of cancer later in my child's life, but the actual potential
for a healthy life is very nearly the same as that of other children. The imaging study does not add to risks
for birth defects. Birth defects occur in small numbers of pregnancies even without exposure to radiation.
 You will be given intravenous contrast during the scan. The FDA has not confirmed the safety of this
contrast in pregnancy. Intravenous contrast can cross the human placenta and enter the fetus when given in
usual clinical doses, but no well-controlled studies of the effects of this media have been performed in
pregnant women. Tests in animals have shown no evidence of increased cancer or birth defects.
I understand this document and have had the opportunity to have my questions answered. I am aware that
the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to
me regarding the outcome of this pregnancy. I agree to have the imaging study performed.
Patient's Name (printed)
Patient's Signature
Patient's Agent or Representative
Relationship to Patient
(If patient unable to consent) Date Signing: _, 20 Physician's Acknowledgement
The undersigned confirms that informed consent, as described above, has been given by the patient. I have
also discussed the possible need for contrast including the potential risks, benefits and consent was
obtained.
Referring Physician's Signature  Emergent situation precluded obtaining written informed consent. Emergency Rationale: Please fax a copy of this form to Medical Physics at 444-4446, and place a copy in the patient's chart. Rhode Island Hospital
Patient Information Sheet for Radiation Risks in Pregnancy
Your doctor has recommended that you have an imaging study to help in your care. Pregnant women may
be concerned that radiation from these tests could harm the baby in some way. There is no specific amount
of x-ray radiation that is totally free of adverse affects, so risks can never be said to be zero, however, in
your case, the amounts of radiation used to make the pictures is very small. Common imaging studies use
low doses of radiation and the risks from these studies are much smaller than the normal risks of
pregnancy. The imaging study your doctor has ordered might slightly increase the possibility of cancer
later in the child's life, but the actual potential for a healthy life is very nearly the same as that of other
children. The imaging study does not increase the risk of birth defects.
Birth defects occur in 1 in 33 (3.0%) of all babies at birth, and cancer occurs in 1 or 2 in 1,000 children.
Therefore a small percentage of all babies will have or will develop one of these problems whether the
imaging study is performed or not. We can never guarantee that a baby will not have any of these problems.
What we can say is that the chance of one of these problems occurring is not significantly increased by
most of the examinations that we use for diagnosis. We would not recommend this study unless we felt
that the information we will get from it is necessary to give you the best possible care.

Radiation Risks in Perspective
The millisievert (mSv) is the measurement used to assess the amount of radiation. Each year, people who live
in New England are exposed to about 3 mSv of radiation from naturally occurring sources including radon and
cosmic rays.
The following are the approximate radiation doses to the mother from common radiology examinations:
Chest X-ray
Abdomen or Pelvis CT
The largest dose of 10mSv may be taken to have a risk to the mother that is comparable to the risk of dying in
an automobile accident when driving a distance of 8,000 miles.
References:
1. ACR Practice Guidelines for Imaging Pregnant or Potentially Pregnant Adolescents and Women with
Ionizing Radiation- 2008 (Res. 26)
2. Cohen and Lee, "A Catalogue of Risks," Health Physics, vol. 36, June 1979
3. Centers for Disease Control and Prevention (CDC). Birth Defects: Frequently Asked Questions July
18,2007
4. American Cancer Society: Cancer Statistics 2008

Source: http://www.lifespan.org/WorkArea/DownloadAsset.aspx?id=24090