Often times services may consult radiology directly for a requested procedure. This is an excellent opportunity to be able to speak directly with the provider(s) who is ordering the procedure and make sure you are able to collect pertinent information quickly. It is important to realize that much of fielding a consult appropriately will depend upon the procedure in question, however some aspects are universal across radiology procedures.
WHY IS THIS PROCEDURE BEING REQUESTED?
It is important to realize that sometimes when fielding a radiology procedure consult it may not be possible to conduct a complete chart review however one question that should be answered is “why should this procedure be performed?”. Answering this question involves expounding upon a few key related components that really revolve around establishing what the indication is for the procedure (for more information regarding procedural indications please refer to this page). Here are some guiding questions to help establish what the indication is (as often times ordering providers may not necessarily have a clear indication that can be communicated easily).
- What clinical question are you hoping to answer? In the case of diagnostic procedures (such as various biopsies, tissue samplings) it is important to understand what clinical question is being asked PRIOR to the procedure to make sure that the procedure in question can actually answer the posed question.
- How does the intervention change the clinical management of the patient? In the case of any type of intervention, it is important to make clear what impact this intervention will have on the patient’s care. In cases where the intervention will not alter patient management at all, the procedure may not truly be indicated. Conversely if the patient’s clinical course completely rests upon the radiology procedure in question this is important to appreciate.
WHEN SHOULD THIS PROCEDURE BE PERFORMED?
One of the initial things to establish when fielding a consult is the desired or required timing of the radiology procedure in question. This will completely influence the nature of the consult as procedure requests will be triaged relative to their urgency. Here is an organized way to approach establishing the timeline:
- Is performing this procedure emergent (does the patient’s immediate safety depend upon it)? In some cases the radiology procedure in question may be the most important intervention for preserving the patient’s safety (i.e. a interventional radiology embolization of a bleeding vessel in a hemodynamically unstable patient). Under these circumstances the consult may be expedited and the attending who will ultimately be performing the procedure will likely be involved quickly in the decision making process.
- Is this procedure urgent (does it play a critical role in the patient’s care)? Short of medical emergencies, there are more urgent requests for radiology procedures that will significantly impact the overall care of the patient, and should be prioritized if possible to be done as soon as possible. Establishing the role of the procedure in altering clinical management is very helpful in establishing urgency.
- If the patient is an inpatient, can the procedure be performed as an outpatient? In certain cases inpatients will have requests for radiology procedures that are not urgent/emergent and can be performed as an outpatient. In some cases it is better for the patient’s care for them to be discharged from the hospital and then return for the procedure in question vs. staying inpatient for a procedure that is not time sensitive.
ARE THERE ALTERNATIVES TO THE PROCEDURE?
In a number of instances, radiology procedures may have alternatives that should be attempted before a procedure is performed under imaging guidance. An example of this can be a lumbar puncture that should first be attempted by palpation before utilizing fluoroscopy or CT guidance.
The topic of procedural alternatives is a nuanced one and is often specific to each procedure. In certain cases it may be unsafe to try this alternative or the chance of failure may be so high that performing the radiology procedure may be the most appropriate first step.
It is important that while fielding the consult alternatives to the procedure (if they exist) are explored and it is clarified if they have been attempted in the past or why they have not been attempted.
IS THE DESIRED PROCEDURE TECHNICALLY POSSIBLE TO PERFORM?
Even when procedures are indicated, their can be technical limitations that may make them not possible to perform. A very common example is the consult for draining an intra-abdominal abscess. While draining such a collection percutaneously is a very reasonable request, if the abscess is surrounded by sensitive anatomy (such as large vessels) and there is no clear window to reach the collection percutaneously, the procedure can not be performed.
Reviewing the patient’s imaging is a very effective way to try and establish if the desired procedure is technically feasible. In certain cases if no prior imaging exists, trying to address this question may require that diagnostic imaging is performed prior to attempting any procedure.
DOES THE PATIENT HAVE SAFETY CONCERNS THAT ARE RELEVANT TO THE PROCEDURE?
It is important to review common safety concerns for a patient when considering performing a radiology procedure. Some of these safety concerns will depend on the specific procedure, however there are some universal ones that are important to consider for most all cases. They are organized into sub categories below:
Hemodynamic Decompensation Risk
Certain patients may not be hemodynamically stable (such as those that are actively bleeding or those that require pressers to support their blood pressure). If patients are at high risk for hemodynamic decompensation they often times will need to be stabilized prior to receiving the radiology procedure in question (unless the radiology procedure is the most appropriate way to stabilize the patient). It can be useful to ask ordering providers if their patients are hemodynamically stable if there is any confusion about this. Specifics to keep an eye out for include:
- Are the patients blood pressure and heart rate stable? Evaluating blood pressure and heart rate trends can be useful to evaluate for hemodynamically stability.
- Does the patient require pressers to maintain their blood pressure? patients that require blood pressers (especially multiple pressers at higher doses) are poor candidates for most procedures
- Is the patient actively bleeding (hemoglobin trend/transfusions)? looking for clues such as recent or current blood transfusions can help identify if a patient may actively be bleeding especially in the setting of a downtrending hemoglobin.
Respiratory Decompensation Risk
Patients who are hemodynamically stable may still be at risk of respiratory decompensation. For most radiology procedures, the patient’s will be positioned flat which in some cases can worsen a patient’s respiratory status. For those patients close to respiratory decompensation, this may be enough to cause respiratory compromise.
Additionally, medications that are used for sedation and pain management may further comprise a patient’s respiratory status (such as fentanyl causing respiratory depression) and may not be safe to administer to certain populations of patients.
Patients who are at high risk of aspiration may not be ideal candidates for certain radiology procedures that require them to be laid flat as well as procedures that are commonly performed with sedation.
Typically the best way to reduce the risk of aspiration in a patient who will receive sedation is to fast prior to the procedure. There are various guidelines, however a common one is to fast for 8 hours prior to the procedure.
Patients may have allergies to materials used during certain radiology procedures (such as iodinated contrast). A patient’s allergies need to be reviewed to make sure that this risk is contextualized (and that pre-medication is coordinated if required).
Many radiology procedures involving puncturing the skin at least one time, and some may also involve more extensive aspects that carry a risk of bleeding. The specific guidelines regarding relative and absolute contraindications to a procedure as it relates to bleeding risk may vary based upon which set of guidelines are being followed, however it is always useful to gather certain key information.
- Is the patient’s INR elevated? typically values above 1.5 are considered elevated for radiology procedures and increase bleeding risk.
- Dos the patient have low platelets? typically values below 50,000 are considered low for radiology procedures increase bleeding risk.
- Is the patient on any medications that increase bleeding risk (anticoagulants)? there are many medications that can increase the risk of bleeding. The practices regarding anticoagulation can vary depending on which are used, however it is always important to make sure all medications that a patient is taking which may increase the risk of bleeding are accounted for.
Evaluating the risk of infection can be challenging and often depends on the specific patient and radiology procedure in question. This is further complicated by the fact that many radiology procedures are required for source control/diagnosis of an active infection. In general it is useful to characterize if the patient currently has an active infection which may in turn lead to an infection related complication if a specific radiology procedure is performed. Specifics to evaluate for are:
- Recent infection history? is the provider or the patient aware of any recent infections that they may have had (or currently have)?
- Vital sign trends concerning for infection/sepsis: fevers, hypotension, tachycardia (in the right context) can suggest an ongoing infection
- White blood cell count trend: this can be useful in certain cases to contextualize infection status
- Current antibiotics: often times patients treated with antibiotics currently have some history of infection/special infectious disease considerations. It is important to review these medications.
Renal Injury Risk (Contrast Related)
The impact of intravenous contrast on renal function and its association with renal injury is a bit of a contested topic. With this in mind it is important to evaluate for the possibility of renal injury (or any objective/subjective concern for renal injury) by evaluating a few things:
- Is the patient dialysis dependent? patients who are dialysis dependent may by at increased risk to renal injury in certain cases. While they are already receiving dialysis, in some instances the patient’s may still retain some renal function that their nephrologist will wish to preserve. In these cases it is often important to make sure the ordering physician/nephrologist is in a agreement that the patient may receive contrast.
- Glomerular filtration rate: typically patients with a GFR 60 and above are considered to be low risk for renal injury from contrast administration. In reality, those with a GFR lower then 60 may still be safe to receive contrast (however this may need to be a discussion with the ordering provider).
- Creatine trend: patients with elevated creatine trends may currently be suffering from renal injury, and receiving contrast may be contraindicated in these circumstances.
Page Updated: 12.22.2019