Interventional Procedures SON 2814 Clinical Practicum 2 THE ROLE OF ULTRASOUND DANIEL CLANCY MBA, RDMS HARRY H HOLDORF PHD, MPA, RDMS, RVT

Interventional

ProceduresSON 2814

Clinical Practicum 2

THE ROLE OF ULTRASOUND

DANIEL CLANCY MBA, RDMS

HARRY H HOLDORF PHD, MPA, RDMS, RVT

Objectives:

After completion of this learning packet the reader will be able to:

1. State the importance of implementing guidelines to ensure patient safety when undergoing invasive procedures.

2. State what is needed in each of the following steps:Pre procedure patient preparationPre procedure room preparationPre procedure instrumentation readinessCompletion of all tasks involved in any given invasive/interventional ultrasound guided procedure

Table of Contents

▪ Introduction

▪ Patient Safety

▪ Clean vs. Sterile technique

▪ Site Marking & Verification for Invasive and/or High Risk Procedures

▪ CVC: Central line Venous catheters

▪ The Seldinger Technique

Table of Contents

▪ Minimum Access

▪ Aspiration Drainage Biopsy

▪ Cyst Aspiration

▪ Paracentesis

▪ Thoracentesis

▪ Drainage▪ Supply choice

Table of contentsTypical Procedures that require ultrasound

guidance or support▪ Amniocentesis

▪ CVS

▪ PUBS

▪ Cardiac Catherization

▪ TIPS

▪ Pericardiocentesis

▪ Thyroid nodule biopsy

▪ Breast biopsy

▪ Needle Localization (for Breast)

▪ FNA vs. Core biopsy

▪ Liver biopsy

▪ Renal biopsy

Table of ContentsTypical Procedures that require ultrasound

guidance or support

▪ Uterine Fibroid Embolization

▪ Image-guided Vena Cava Filter Placement

▪ Hysterosalpinography

▪ Sonohysterogram

In closing…

Neurocardiogenic Syncope

Summation

Introduction

▪ What is an invasive procedure?

▪ What is the typical role of the sonographer in an invasive procedure?

▪ How long do invasive procedures take?

▪ How do I get checked out for an invasive procedure?

▪ If an invasive procedure is done in my Ultrasound room, what am I responsible for?

Informed consent?Sterile Kit?Gloves?Drapes?

What is an Invasive Procedure?

▪ An invasive procedure is one that penetrates or breaks the skin or enters a body cavity.

▪ Examples of invasive procedures include those that involve perforation, an incision, a catheterization, or other entry into the body.

▪ Surgery is a typical medical invasive procedure.

Who is in the room?

▪ Who may be in the room for an invasive procedure?▪ Physician▪ Nurse▪ Technologist▪ Student▪ Etc…

How long do invasive procedures take?

▪ Typically, count on a procedure to last at least an hour.

If an invasive procedure is done in my Ultrasound room, what am I responsible for?

▪ Room set-up

▪ Patient identification

▪ Patient Preparation

▪ Instrumentation set-up

▪ Pre-Procedure Exam? ▪ Obstetrics▪ Pelvic▪ Abdomen▪ Etc.

Patient Safety and Invasive Procedures

Objectives for Patient Safety

To understand The main causes of adverse events in surgical and invasive procedural care.

How the use of guidelines, verification processes and teamwork can facilitate the correct patient receiving the correct treatment at the appropriate time and place.

Knowledge Requirements

The main types of adverse events associated with

surgical and invasive procedural care.

The verification processes for improving surgical and

invasive procedures' care.

Performance Requirements

Follow verification processes to avoid wrong patient,

wrong side and wrong procedure errors (e.g. a surgical

checklist).

Practice techniques that reduce risks and errors (e.g.

time-outs, briefings, debriefings, stating concerns).

Participate in an educational process for reviewing

mortality and morbidity.

Actively engage as a team member.

Actively engage with the patient at all times.

Patient Safety continued…

The main types of adverse events associated with invasive procedural and surgical care

▪ Poor infection control methods

▪ Inadequate patient management

▪ Failure by health-care providers to communicate

▪ effectively before, during and after operative

▪ procedures

SUMMARY for Patient Safety

The value of guidelines cannot be overstated.

Health-care professionals need to understand the reasons for the guidelines.

Protocols and verification steps can minimize mistakes in patient identity.

The use of everyday techniques can improve communication and minimize errors.

Dirty vs. Sterile Technologist…

▪ “Clean vs. Sterile Technologist/Technique

▪ For practical purposes, "clean" refers to using regular gloves and standard precautions while performing a procedure. "Sterile" has another set of standards which includes donning and using sterile gloves, working within a determined sterile field, and re-gloving (or possibly starting over) whenever those standards are broken.

Site Marking & Verification for Invasive and/orHigh Risk Procedures

▪ The Joint Commission has set forward guidelines to provide for safe care of patients undergoing invasive procedures.

▪ Site marking and verification is provided to ensure that guidelines are followed.

▪ The key element of any site marking and verification policy is to ensure that the right patient receives the intended procedure.

Site Marking & Verification for Invasive and/orHigh Risk Procedures

▪ Elements of the process for site marking and verification are:▪ Scheduling▪ Informed consent▪ Patient identification and verification of the procedure to be

performed▪ Site marking (as required related to level, laterality, multiple

structures)▪ “Pause for the Cause”

▪ The pause for the cause is defined as an active pause as near to the start of the procedure as possible. This pause includes the final confirmation of the patient’s identification, the procedure to be done, and the site of the procedure when necessary.

▪ The pause calls for all members of the team involved with the procedure to actively agree that it is safe to proceed.

▪ Documentation of the pause and other elements is required.

Clean vs. Sterile

▪ Clean is typically used for more routine and non-invasive procedures, while sterile is used for invasive procedures. Clean can be thought of as being a barrier to mixing bodily fluids, while sterile is truly working without organisms.

▪ Example: Giving a subcutaneous shot of insulin requires clean procedures, while inserting a Foley catheter requires sterile procedures. It is about the risk of infection from both parties involved, but more for the protection of the patient.

▪ Imagine if someone was inserting a catheter into your body without using sterile procedures - who knows what is on that catheter if they've been flinging it around and not worrying about their gloves touching surfaces...and now it's going into your urethra!

CVC : Central Line Venous Catheters

▪ A central venous catheter, also called a central line, is a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products over a long period of time, usually several weeks or more. A catheter is often inserted in the arm or chest through the skin into a large vein. The catheter is threaded through this vein until it reaches a large vein near the heart.

▪ A catheter may be inserted into the neck if it will be used only during a hospital stay.

Central Line Venous Catheter orPICC line: Peripherally Inserted Central Catheter

CVC

Central venous catheters are used to:

▪ Give long-term medicine treatment for pain, infection, or cancer, or to supply nutrition. A central venous catheter can be left in place far longer than an intravenous catheter (IV), which gives medicines into a vein near the skin surface.

▪ Give medicines that affect the heart, especially if a quick response to the medicine is wanted.

▪ Give large amounts of blood or fluid quickly.

▪ Take frequent blood samples without having to "stick" someone with a needle.

▪ Receive kidney dialysis in the presence of kidney failure.

▪ A central venous catheter can be left in place far longer than an intravenous catheter (IV), which gives medicines into a vein near the skin surface. Also, a central venous catheter allows a person to receive IV medicines at home.

The Seldinger Technique

▪ The Seldinger technique, also known as Seldinger wire technique, is a medical procedure to obtain safe access to blood vessels and other hollow organs.

▪ It is named after Dr. Sven-Ivar Seldinger (1921-1998), a Swedish radiologist who introduced the procedure in 1953.

The Seldinger Technique

Minimum Access – Maximum Result

▪ Interventional Radiology is pin hole surgery performed with the aid of X rays, CT and Ultrasound by specially trained doctors called Interventional Radiologists.

▪ 80% of these procedures use skin incisions smaller than 5 millimetres.

▪ 90% of these procedures use only local anesthetic, sometimes with sedation.

▪ 80% of these patients go home the same day.

Less invasive option than traditional surgical procedures

AspirationDrainageBiopsyUltrasound Guided Procedures

Aspiration

Cyst AspirationParacentesis

(Ascites)

Thoracentesis (Pleural Effusion)

Cysts

Cysts are very commonAccurately Diagnosed with UltrasoundCysts do not usually require intervention or follow-up, unless there is significant tenderness

Technique for Cyst Aspiration

The skin is cleaned, and numbed with a topicalanesthetic. With the aid of Ultrasound a small needle isadvanced into the cyst and suction is applied to draw out the fluid out causing the lump to collapse.

Cyst Aspiration

Cyst Aspiration Needle

Fluid Drained

Ultrasound Guided Paracentesis

Fluid in the Abdomen Puncture Site

Paracentesis

Paracentesis

Where to start?

• It is very helpful to get an ultrasound scan of the ascites before the procedure.

• The radiologist will mark a spot on the skin, this is the site of the needle insertion.

Two important things to know

▪ What is the distance from the skin to the fluid (usually 1cm).

▪ What is the midway point of the collection (usually 3cm).

Evaluation of Paracentesis

Paracentesis Needle

Thoracentesis

Thoracentesis (Pleural Fluid)

Thoracentesis is a procedure to remove fluid from the space between the lungs and the chest wall called the pleural space. It is done with a needle (and sometimes a plastic catheter) inserted through the chest wall. Ultrasound pictures are often used to guide the placement of the needle. This pleural fluid may be sent to a lab to determine what may be causing the fluid to build up in the pleural space.

Therapeutic Vs. Diagnostic Thoracentesis

Therapeutic Thoracentesis

▪ Therapeutic thoracentesis is one of the most commonly performed medical procedures. “Therapeutic thoracentesis" refers to removal of a large volume of pleural fluid for relief of symptoms.

Diagnostic Thoracentesis

▪ "Diagnostic thoracentesis" refers to removal of a small volume of pleural fluid for analysis

Drainage

Your physician is concerned that you have an area of fluid that should not bethere, called a collection. These collections usually appear in the chest or in the abdomen (tummy). Using the ultrasound machine to guide him, aRadiologist will insert a tube or a drain through your skin into the fluid. This tube will allow the fluid to drain into a bag and be removed from your body.

Indications for Drainage

Any fluid collections that are accessibleComplicated Diverticular AbscessCrohn’s disease related Abscess Appendicular AbscessLiver Abscess

Contraindications for Drainage

Abscess is not accessible

Patient has abnormal bleeding (PT, PTT, INR)

Tools for a Drainage

Needle Choice

▪ Typical abscess fluid is readily aspirated through an 18-gauge needle, which has approximately one-twentieth the resistance to fluid flow of a 21- to 22-gauge needle.

▪ Viscous or debris-laden fluid is more likely to cause a false-negative aspirate with a 21-gauge needle as only clear supernatant may return through the needle.

▪ An 18-gauge needle is easier to control and image and accepts a 0.038-inch guidewire

▪ There is no clinically significant difference in needle trauma between the 18 and 22-gauge needles when a catheter is placed through the same tract. (This has been demonstrated for arteriotomy.)

▪ The 21-gauge needle may be used to minimize trauma for a challenging localization, low-probability fluid collection, or personal preference.

Before you Start make sure you are Completely Prepared

Supplies•Iodine solution•Cotton balls, towel clamp and cup•Two 20-cc syringe•Spinal needle (22 g x 9 cm)•Four sterile blue towels•Gauze sponges

Amniocentesis tray

Ultrasound marks the spot, two-thirds of the time

Typical Invasive Procedures that require Ultrasound Guidance or support

Amniocentesis

Why is it done?

Used in prenatal diagnosis of chromosomal abnormalities and fetal infections and for sex determination. A small amount of amniotic fluid, which contains fetal tissues, is sampled from the amniotic sac surrounding a developing fetus, and the fetal DNA is examined for genetic abnormalities. The most common reason to have an "amnio" is to determine whether a baby has certain genetic disorders or a chromosomal abnormality, such as Down syndrome. Amniocentesis is usually done when a woman is between 14 and 16 weeks pregnant.

What is your responsibility?

Prep the room, prep the patient, perform a preliminary Fetal ultrasound exam, locate a free pocket of amniotic fluid, and direct the needle.

Amniocentesis

CVS: Chorionic Villus Sampling

Why is it done?

Chorionic villus sampling (CVS) is a prenatal test in which a sample of chorionic villi is removed from the placenta for DNA testing. The sample can be taken through the cervix (trans-cervical) or the abdominal wall (transabdominal).


Prep the room, prep the patient, perform a preliminary ultrasound exam, guide the image if necessary.

CVS

PUBS: Percutaneous Umbilical Blood Sampling

Why is it done?

A genetic test that examines blood from the fetal umbilical cord to detect fetal abnormalities. Fetal and maternal blood supply are typically connected in utero with one vein and two arteries to the fetus. The umbilical vein is responsible for delivering oxygen rich blood to the fetus from the mother; the umbilical arteries are responsible for removing oxygen poor blood from the fetus. This allows for the fetus’ tissues to properly perfuse. PUBS provides a means of rapid chromosome analysis and is useful when information cannot be obtained through amniocentesis, chorionic villus sampling, or ultrasound (or if the results of these tests were inconclusive). This test carries a significant risk of complication and is typically reserved for pregnancies determined to be at high risk for genetic defect.


Prep the room, prep the patient, perform a preliminary ultrasound exam, guide the image if necessary.

PUBS

Cardiac Catheterization

Why is it done?

Cardiac catheterization is used to diagnose and treat some heart conditions. A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart.


Typically, Cardiac Catheterization is preformed under Radiological guidance. But, you should know the anatomy routes of access for the catheter.

Cardiac Catheterization

TIPS: Transjugular intrahepatic Portosystemic shunt

Why is it done?

Normally, blood coming from the esophagus, stomach, and intestines first flows through the liver. When the liver is damaged and there are blockages, blood cannot flow through it very easily. This is called portal hypertension (increased pressure and backup of the portal vein). The veins can then break open (rupture), causing serious bleeding. Transjugular intrahepatic porto-systemic shunt (TIPS) is a procedure to create new connections between two blood vessels in the liver.


You may be asked to perform a preliminary liver ultrasound exam documenting Doppler flow patterns of the Portal and hepatic veins, and hepatic artery.

TIPS

Pericardiocentesis (Pericardial Tap)

Why is it done?

Pericardiocentesis is the aspiration of fluid from the pericardial space that surrounds the heart. This procedure can be life saving in patients with cardiac tamponade, even when it complicates acute type A aortic dissection and when cardiothoracic surgery is not available.


▪ Performing a preliminary exam

▪ Providing ultrasound guidance

▪ Performing a post-procedure exam

Subxiphoid view of he heart demonstrating a moderate sized pericardial effusion.

Pericardiocentesis

Needle tip within the pericardial space

Thyroid nodule biopsy

Why is it done?

A fine needle aspiration biopsy of the thyroid gland is an effective method to determine whether or not a thyroid nodule is cancerous. The procedure is relatively simple and usually takes less than 20 minutes. Complications are rare but include bleeding, bruising, and infection. Results are generally available within one week and help determine what (If any) interventions or treatments are necessary.

▪ What is your responsibility?

▪ Patient Prep, Room Prep, Instrumentation prep, Preliminary Exam, Ultrasound guidance

Thyroid Nodule Biopsy

Breast Biopsy

Why is it done?

A breast biopsy is a procedure to remove a small sample of breast tissue for laboratory testing. Breast biopsy is a way to evaluate a suspicious area in your breast to determine if it is breast cancer.


▪ Patient Prep

▪ Room Prep

▪ Instrumentation prep

▪ Preliminary Exam

▪ Ultrasound guidance

Breast Biopsy

Needle Localization (Breast) AKA Needle Loc

Why is it done?

Abnormal tissues may be difficult to find during surgery even when they show up clearly on a mammogram. When abnormal tissue is discovered, the most effective way to reduce the risk of cancer is to remove the tissue entirely.

In order for the surgeon to remove the area of breast tissue that contains the area of concern, he or she will need a guide to show the exact location of the abnormality. Needle localization is most often performed immediately prior to surgery on patients who are having surgical breast biopsies or lumpectomies.

The breast localization procedure will result in precise pinpointing of the abnormality thereby increasing the surgeon’s ability to remove all of the abnormal tissue while reducing the removal of healthy tissue. It also reduces the length of time in surgery.

The needle localization may be performed under ultrasound guidance, mammographic guidance, or MRI guidance depending on which type of imaging best shows the abnormality. The most common way to perform needle localization is to use mammographic guidance.


Patient Prep, room prep, instrumentation prep, perform a preliminary exam

Breast Needle Localization

Needle Localization utilizing Mammography

FNA vs. Core Biopsy

▪ In fine needle aspiration biopsy (FNAB), the doctor uses a very thin needle attached to a syringe to withdraw a small amount of tissue from the suspicious area. This tissue is then looked at under a microscope. The needle used for FNAB is thinner than the ones used for blood tests.

▪ Core needle biopsy (CNB) is much like an FNAB. A slightly larger, hollow needle is used to withdraw small cylinders (or cores) of tissue from the abnormal area in the breast. The needle is put in 3 to 6 times to get the samples, or cores. This takes longer than an FNAB, but it’s more likely to give a clear result because more tissue is taken to be checked. A CNB can cause some bruising.

FNA

Core Biopsy

Liver Biopsy

Why is it done?

A liver biopsy is a procedure in which a small needle is inserted into the liver to collect a tissue sample.

This is performed as an office or outpatient procedure or during surgery. The tissue is then analyzed in a laboratory to help doctors diagnose a variety of disorders and diseases of the liver.


Patient Prep, Room Prep, Instrumentation Prep, Preliminary Exam, Ultrasound Guidance, Post-Procedure Exam

Liver Biopsy

Renal Biopsy

Why is it done?

Renal biopsy (also kidney biopsy) is a medical procedure in which a small piece of kidney is removed from the body for examination, usually under a microscope.

Microscopic examination of the tissue can provide information needed to diagnose, monitor or treat problems of the kidney.


Patient Prep, Room Prep, Instrumentation Prep, Preliminary Exam, Ultrasound Guidance, Post-Procedure Exam

Renal Biopsy

Uterine Fibroid Embolization

Why is it done?

Uterine fibroid embolization (UFE) is a minimally invasive procedure used to treat fibroid tumors of the uterus which can cause heavy menstrual bleeding, pain, and pressure on the bladder or bowel.

It uses a form of real-time x-ray called fluoroscopy to guide the delivery of embolic agents to the uterus and fibroids. These agents block the arteries that provide blood to the fibroids and cause them to shrink.

Studies have shown that nearly 90 percent of women who undergo UFE experience significant or complete resolution of their fibroid-related symptoms.

What is your responsibility?Perform Preliminary ultrasound examPerform post-procedure ultrasound exam

Uterine Fibroid Embolization

Image-Guided Vena Cava Filter Placement

Why is it done?

An inferior vena cava filter (IVC filter) is a type of vascular filter, a medical device that is implanted by interventional radiologist or vascular surgeons into the inferior vena cava to presumably prevent life-threatening pulmonary emboli.

What is your responsibility?Perform a preliminary examPerform a post-procedure examMaintain Ultrasound equipment

Vena Cava Filter Placement

Hysterosalpinography

Why is it done?

Hysterosalpingography is an x-ray examination of a woman's uterus and fallopian tubes that uses a special form of x-ray called fluoroscopy and a contrast material. Performed to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes. It entails the injection of a radio-opaque material into the cervical canal and usually fluoroscopy with image intensification. A normal result shows the filling of the uterine cavity and the bilateral filling of the fallopian tube with the injection material.


None. You may be asked to perform a follow-up Sonohysterogram. So, learn how to read these images.

Hysterosalpinography

Sonohysterography/Sonohysterogram

Why is it done?

Saline sonohysterogram is an outpatient ultrasound procedure designed to evaluate the endometrial cavity (the inside part of the uterus) and the endometrium (the lining of the endometrial cavity) for polyps, bleeding, and general abnormal endometrial contour.

A speculum is introduced and a narrow catheter is placed in the vagina, through the cervix, and into the uterine cavity. The ultrasound examination is continued while sterile saline (salt water) is put into the uterus. The saline solution fills the uterus, helping to outline the uterine walls and cavity. This shows abnormalities such as fibroids, polyps, or scar tissue inside the uterus.

What is your responsibility? Performing a preliminary pelvic exam. Performing the exam while the saline is injected into the endometrium.

Sonohysterogram

Neurocardiogenic Syncope

▪ Syncope (fainting) is one of the most common medical ailments encountered in clinical practice.

▪ Although frequently thought of as a condition with a neurological origin, it’s actually a cardiovascular problem - as such, a neurologic work-up is seldom rewarding.

▪ The two main causes of syncope are cardiac arrhythmias and neurocardiogenic (vasovagal, vasodepressor) syndromes.

▪ In both of these conditions, blood circulation to the brain is reduced, resulting in temporary loss of consciousness.

When does Neurocardiogenic Syncope lead to Symptoms?

Neurocardiogenic syncope occurs in predisposed individuals in the following settings:

▪ after prolonged periods of quiet upright posture (such as standing in line)

▪ after being in a warm environment (such as in hot summer weather, a hot crowded room, a hot shower or bath)

▪ immediately after exercise

▪ after emotionally stressful events (having blood drawn, being scared or anxious)

▪ some individuals get symptoms soon after eating, when blood flow has shifted to the intestinal circulation during the process of digestion

IN SUMMARY: Ultrasound for Procedures

▪ Various probes are suited to different uses due to differing depth or penetration/resolution.▪ Vascular probes: Best shallow resolution to delineate vessel size

and potential clot.▪ Located or guided procedures

▪ Located…target in site, needle not followed▪ Guided…needle and guide wire followed scanning actively, tilting and

translating (sliding) the probe

▪ Problems: Scanning in and out of plane with short and long axis (now you see it, now you don’t.

Ultrasound for procedures

▪ Tips for Ultrasound guided procedures▪ Remember that collapsing veins disappear with compression▪ Echogenic needles sometimes help…more artifact, thus easier to

see

▪ Know your anatomy: example - for Central line Placement - Central venous catheters (CVC)▪ IJV vs. Subclavian

▪ Most kits are Seldinger

▪ Ascites drainage: ▪ Use phased array on an abdominal setting or curved array▪ You may see black fluid and bowel▪ If hematoma, often bits of clot seen floating in fluid

Ultrasound for Procedures

▪ Pericardial centesis▪ Subcostal or apical

▪ THE BIG ONE: SURGEONS DON’T LIKE TO DO

▪ Keep your room stocked, or stocked nearby

▪ Keep your room clean

▪ Make sure your machine is working properly

▪ Stay calm

RADIOLOGIST PREFERENCE

QUESTION: FOR ANY GIVEN PROCEDURE: HOW DO I KNOW WHICH SET-UP TO USE?

ANSWER:

1. KNOW YOUR RADIOLOGIST, OBSTETRICIAN, VASCULAR

SURGEON, ETC…

2. HAVE AS MANY DIFFERENT GLOVES, TRAYS, NEEDLES, ETC

3. AVAILABLE AS POSSIBLE

4. HOPE FOR THE BEST

Ultrasound Procedure.YOU CAN DO THIS!!!!!!

Documents

Interventional Procedures SON 2814 Clinical Practicum 2 THE ROLE OF ULTRASOUND DANIEL CLANCY MBA, RDMS HARRY H HOLDORF PHD, MPA, RDMS, RVT