performing-image-guided-procedures

name	performing-image-guided-procedures
description	Documents image-guided biopsy, drainage, and injection procedures with technique and specimens. Use when performing IR procedures, documenting image-guided interventions, or recording procedural details.
tags	["process","radiology"]
metadata	{"author":"casemark","practice_areas":["Radiology","Diagnostic Imaging"],"document_types":["Procedure Note"],"skill_modes":["Execution"]}

Performing Image Guided Procedures

Documents image-guided biopsy, drainage, and injection procedures with technique and specimens.

Why This Skill Exists

Image-guided procedures — biopsies, drainages, aspirations, and injections — are among the highest-risk activities in radiology, carrying potential for hemorrhage, pneumothorax, infection, organ injury, and procedural failure. The ACR-SIR Practice Parameter for Performing and Interpreting Diagnostic Procedures mandates comprehensive procedural documentation including informed consent, technique details, specimens obtained, complications, and post-procedure care. Inadequate procedure notes are a leading source of liability in interventional radiology malpractice claims.

CMS documentation requirements tie reimbursement to specific procedure-note elements, and The Joint Commission requires Universal Protocol compliance (correct patient, correct site, correct procedure) for all invasive procedures. The Society of Interventional Radiology (SIR) quality-improvement guidelines define complication thresholds for common procedures; documentation must capture enough detail to enable quality review and meet these standards. This skill ensures every image-guided procedure is documented with the completeness required by regulatory, accreditation, and medicolegal standards.

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Checkpoint A: Pre-Draft Intake (Mandatory)

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

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Step 1: Pre-Procedure Safety Checks

Universal Protocol (Joint Commission)

Step	Action	Verification
Correct patient	Two-identifier verification (name + DOB or MRN)	Verbal + wristband
Correct site	Mark laterality if applicable	Visible mark on patient
Correct procedure	Verify order matches planned procedure	Consent form matches
Time-out	Announce patient, procedure, site, laterality, allergies, antibiotics	All team members pause and confirm
Implant verification	N/A for most (verify if placing hardware)	—

Coagulation Parameter Thresholds (SIR Consensus Guidelines 2019)

Procedure Category	INR Threshold	Platelet Threshold	Anticoagulation Hold
Low bleeding risk (thoracentesis, paracentesis, superficial biopsy)	Correct if >2.0	Correct if <20,000	Hold per institutional protocol
Moderate bleeding risk (deep visceral biopsy, nephrostomy)	Correct if >1.5	Correct if <50,000	Hold warfarin 5 days; hold DOACs 48h
High bleeding risk (renal biopsy, transjugular liver biopsy)	Correct if >1.5	Correct if <50,000	Hold all anticoagulation; consider bridging

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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)

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Step 3: Specimen Documentation

Biopsy Specimens

Element	Documentation
Number of cores	e.g., "4 core specimens obtained"
Core length/quality	e.g., "each measuring approximately 1.5 cm, tan-white, firm"
Touch preparations	If performed, note number of slides
Specimen destination	Surgical pathology, microbiology, flow cytometry, cytogenetics
Rapid on-site evaluation	If ROSE performed, document adequacy assessment
Fixative	Formalin, saline, RPMI, specific culture media
Labeling	Verified patient identifiers on specimen container

Fluid Specimens

Element	Documentation
Volume	Total volume aspirated (mL)
Appearance	Color, clarity, consistency (serous, serosanguinous, purulent)
Tubes sent	Cell count (purple), protein/LDH/glucose (green), culture (sterile), cytology (dedicated container)
Fluid pocket	Pre- and post-drainage dimensions if applicable

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Step 4: Complication Documentation and SIR Thresholds

Immediate Complication Assessment

Complication	Detection Method	Threshold for Concern
Pneumothorax	Post-procedure CXR or CT	Any new pneumothorax; chest tube if >2 cm or symptomatic
Hemorrhage	Post-procedure imaging + vital signs	Active extravasation, expanding hematoma, hemodynamic instability
Organ injury	Post-procedure imaging	Non-target organ puncture, bile leak, bowel perforation
Vasovagal	Vital signs monitoring	Bradycardia <50, hypotension; treat with atropine and fluids
Infection	Delayed (24–72h)	Fever, increasing pain, elevated WBC

SIR Complication Thresholds (Selected Procedures)

Procedure	Major Complication Threshold	Minor Complication Threshold
CT-guided lung biopsy	Pneumothorax requiring chest tube: <5%	Pneumothorax (any): <25%
CT-guided liver biopsy	Major hemorrhage: <2%	Minor hemorrhage: <5%
Abscess drainage	Sepsis: <5%	Catheter dislodgement: <10%
Paracentesis	Bowel perforation: <1%	Local hematoma: <5%
Image-guided musculoskeletal injection	Infection: <0.1%	Vasovagal: <5%

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).

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Step 5: Post-Procedure Care

Recovery Documentation

Element	Detail
Vital signs	Baseline and at 15, 30, 60 min (minimum)
Post-procedure imaging	CXR for lung biopsy; CT check for abdominal procedures
Activity restrictions	Bed rest duration, weight-lifting restrictions, driving restrictions
Follow-up plan	When to expect pathology results; follow-up appointment
Discharge criteria	Stable vitals, no expanding hematoma, no respiratory distress
Patient instructions	Written discharge instructions with emergency contact information
Anticoagulation resumption	When to restart held medications

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

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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?

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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

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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.