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.

Checkpoint A: Pre-Draft Intake (Mandatory)

What procedure is being performed? (Default: Specify — biopsy, drainage, aspiration, injection, line placement)
What imaging guidance is used? (Default: CT, ultrasound, fluoroscopy, or MRI)
What is the target? (Default: Specific organ, lesion, and location)
Is informed consent documented? (Default: Required — verify before starting)
What is the patient's coagulation status? (Default: Check INR, platelets, anticoagulation status)
Does the patient have relevant allergies? (Default: Contrast, latex, local anesthetic)
What is the planned sedation level? (Default: Local anesthesia — specify if moderate sedation)
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)

| 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 |

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):

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

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 |

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).

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

Checkpoint B: Post-Draft Alignment (Mandatory)

Was the Universal Protocol (time-out) documented?
Is the technique section detailed enough for another radiologist to reproduce the procedure?
Are all specimens documented with destination, fixative, and labeling verification?
Is post-procedure imaging documented with findings?
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

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