Performing Image Guided Procedures

1. What procedure is being performed? (Default: Specify — biopsy, drainage, aspiration, injection, line placement)
2. What imaging guidance is used? (Default: CT, ultrasound, fluoroscopy, or MRI)
3. What is the target? (Default: Specific organ, lesion, and location)
4. Is informed consent documented? (Default: Required — verify before starting)
5. What is the patient's coagulation status? (Default: Check INR, platelets, anticoagulation status)
6. Does the patient have relevant allergies? (Default: Contrast, latex, local anesthetic)
7. What is the planned sedation level? (Default: Local anesthesia — specify if moderate sedation)
8. Are pre-procedure labs adequate? (Default: INR <1.5, platelets >50,000 for most procedures)

Documents to Request

• Signed informed consent form
• Pre-procedure labs (CBC, PT/INR, PTT; creatinine if contrast planned)
• Relevant imaging (CT, US, MRI) showing the target lesion
• Anticoagulation management plan (held or bridged per SIR guidelines)
• Patient allergy list
• Pre-procedure H&P or clinical note
• Pathology requisition forms (for biopsies)
• SIR complication thresholds for the planned procedure

Step 1: Pre-Procedure Safety Checks

Universal Protocol (Joint Commission)

Coagulation Parameter Thresholds (SIR Consensus Guidelines 2019)

Step 2: Procedure Documentation — Required Elements

Informed Consent Documentation

• Procedure name and purpose explained
• Risks discussed (bleeding, infection, pneumothorax, organ injury, non-diagnostic result)
• Alternatives discussed (surgical biopsy, observation, empiric treatment)
• Patient questions addressed
• Consent form signed, dated, and witnessed

Procedure Note Structure

Header:

• Patient identifiers, date, time, location
• Procedure name (CPT-level specificity)
• Performing physician and assistants
• Imaging guidance modality
• Anesthesia type

Indication:

• Clinical indication with relevant history
• Target lesion description (location, size, relationship to critical structures)

Technique (in chronological order):

1. Patient positioning
2. Pre-procedure imaging review and target localization
3. Sterile preparation and draping description
4. Local anesthesia (agent, concentration, volume, location)
5. Sedation medications (if used) with doses and times
6. Access approach (skin entry site, trajectory, distance to target)
7. Needle/device type and gauge
8. Number of passes
9. Guidance method (real-time vs. intermittent; CT, US, fluoro)
10. Specimens obtained (cores, aspirate, fluid) with descriptions
11. Post-procedure imaging (pneumothorax check, hemorrhage assessment)
12. Hemostasis method (manual pressure, gelatin plug, coil)

Step 3: Specimen Documentation

Biopsy Specimens

Fluid Specimens

Step 4: Complication Documentation and SIR Thresholds

Immediate Complication Assessment

SIR Complication Thresholds (Selected Procedures)

Document all complications using the SIR classification: Minor (A = no therapy, B = nominal therapy) or Major (C = requiring hospitalization <48h, D = >48h or escalation, E = permanent adverse sequelae, F = death).

Step 5: Post-Procedure Care

Recovery Documentation

Discharge Instruction Essentials

• Signs/symptoms requiring emergency evaluation (increasing pain, shortness of breath, fever, bleeding)
• Activity restrictions with duration
• Wound care instructions
• Contact numbers (radiology department, emergency line)
• Follow-up appointment and pathology result discussion plan

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Was the Universal Protocol (time-out) documented?
2. Is the technique section detailed enough for another radiologist to reproduce the procedure?
3. Are all specimens documented with destination, fixative, and labeling verification?
4. Is post-procedure imaging documented with findings?
5. Are complications (or absence thereof) explicitly documented?

Quality Audit

• Informed consent is documented and signed before the procedure
• Universal Protocol (time-out) is documented with all elements
• Pre-procedure labs are reviewed and within acceptable thresholds
• Imaging guidance modality is specified
• Local anesthesia and/or sedation are documented with agents and doses
• Needle/device type and gauge are specified
• Number of passes is documented
• All specimens are described and sent to correct destinations
• Post-procedure imaging is performed and findings documented
• Complications are documented (or "no immediate complications")
• Vital signs are monitored and documented in recovery
• Discharge criteria are met and documented
• Written discharge instructions are provided to the patient
• Anticoagulation resumption plan is documented
• Procedure meets SIR quality thresholds

Guidelines

1. Never begin an image-guided procedure without verified informed consent and a completed Universal Protocol time-out.
2. Document the technique in sufficient detail that another interventionalist could understand the approach, even if they were not present.
3. Always perform post-procedure imaging for thoracic and deep abdominal biopsies — do not rely solely on clinical assessment for pneumothorax or hemorrhage.
4. Use SIR consensus guidelines for coagulation management — individual institutional protocols may be more conservative, which is acceptable.
5. Specimen labeling must be verified with two patient identifiers before leaving the procedure room.
6. Document complications using SIR severity classification (Minor A/B, Major C/D/E/F) for quality-assurance tracking.
7. For lung biopsies, position the patient biopsy-side-down after the procedure to reduce pneumothorax risk, and obtain post-procedure chest radiograph at 1–2 hours.