May 31, 2016



UNC Vascular and Interventional Radiology Rotation Guide Welcome to Vascular and Interventional Radiology (VIR). Trainees will be exposed to a wide spectrum of disease and have the opportunity to learn a great deal while impacting many patients’ lives. To maximize the experience, residents must learn how the section operates and interfaces with the entire hospital. Daily responsibilities will require good communication and organizational skills, knowledge of the physical layout of VIR and the hospital, and motivation to learn, teach and grow. Residents will be evaluated based on progress along the Milestone spectrum. Competency-based goals and objectives based on these benchmarks for each level of training are provided separately in the “Interventional Radiology Competency-based Goals and Objectives.” Please refer to those documents for details.VIR Educational Resources:For the first rotation in VIR, all residents should watch the orientation video: Many VIR resources on the education website: rads.web.unc.edu?UNC Health Sciences Library: Radiology Interventional Radiology Requisites – Hard copy also available to residentsVIR Educational ModulesCreated by UNC VIR faculty. Modules include venous access, arterial access and closure, thoracic IR, VIR medications, TIPS, UFE, mesenteric ischemia, IR OncologySIR Consensus Guidelines - useful resource for anticoagulation cutoffs, antibiotics prophylaxis, etc.PDFs of VIR Reference Articles – available on Google DriveSIR-RFS Videos: (Additional webinars are available on the SIR Anticoagulation guide by Dr. Moll – pendingRFS YouTube channel)Image-Guided Percutaneous Drainage of Abdominal Abscesses and Fluid Collections Vena Cava (IVC) Filter Placement Transcatheter Arterial Chemoembolization (TACE) HYPERLINK "" Femoral Access Biopsy and Where to Show Up: 0645-0700 in the second floor VIR conference roomAttendance is mandatory at VIR morning rounds, monthly Grand Rounds, noon conference, inter-disciplinary conferences, morbidity & mortality rounds, and conferences given by visiting speakers. LOGIN:VIR epic login Department IMG VIR H&V UNCMHThis will allow you to see the status board and schedulesOn your first rotation, ask Elad (tech) to give you the “Tech worklist” on Epic so that you can make the list at homeAttending Schedule:VASC 1 (Number 1):First listed on the scheduleThey run the list in the AM and are the primary procedure attendingThey approve cases throughout the day and are the one on call over nightAll residents should check out with this attending prior to leaving each dayVASC 2 (Number 2):Performing cases all day as well but add-ons for the day or new inpatient cases do not go through this personVASC 3 (Number 3):Performs cases if neededReads CVI studies with the CVI residentDivision of Labor:Procedures:Follow any available attending or fellow at first. As you become more comfortable, ask them to supervise you performing the procedure.Resident Responsibilities:Brief Op Note:Post-Procedure tab Op notesPost Procedure Orders:Post-Procedure tab Orders Sets “VIR”“VIR post CVAD” for all lines“VIR post drain” for drains, etc.Post-procedure tab OrdersAny cultures or other labs (verify with the team)Surgical pathology, cytology, FNADictation:In PACS, complete within 24 hrsInpatient - Consenting inpatients and fielding callsResponsibilities/Tips:Betsey, the board runner, is your best friend (40420).Take notes when they run the list at 0700. It will be your job to follow up on labs and contact the teams to clarify orders.Carry the VIR consult pager. The hip phone is also helpful to be able to return pages on the go. It is stored on the charger in the VIR conference room. The Inpatient Board:The board will fill up with orders throughout the day. The team will also page you about the consult.Verify the order is correct (usually it is NOT, especially with lines)Triage based on urgency – Need urgent dialysis or chemo, sick patient that needs access, etc.Check labs/ Anticoagulation (see review of labs below)Review imaging and get approval from VASC 1. Once approved, move the card to the “Approved” column.Consents:Please full discussion of consenting process below.Triage the patients with the board runner after morning rounds and discuss who you should consent first and which patients can come down to be consentedSome patients can be consented down in the VIR hallways – simple procedures (lines) and patients that are awake and alert and can consent for themselves. The board runner will call for them and you will consent them in the department.Prep for the next day:First cases: Discuss appropriate first cases with the board runner (usually at least 4 cases)Good first cases: Lines on stable patientsBad first cases: ICU patients (need ICU transport), cases that need labs checked in the morning, G tubes (need to check barium first)G-Tubes:Routine G tube Prep (MUST be done the day before):Consent the patient or family, write H&POrder NG tube placement if not already in placeObtain barium from board runner and take it to the patient’s nurse and instruct them to administer it via NG tube starting at 2000.Place miscellaneous nursing order to administer barium at 2000 and leave NG tube in place for the procedure.Order KUB at 0500 For decompression/venting for obstruction NO BARIUMInpatient Line Removals:Ask the fellows or upper levels where the nurses keep the line removal kits. They will show you how to do it the first time.Document a brief procedure note and let the board runner know when you pull a line. You will need to do a short dictation. Document that the catheter and cuff were both removed intact. If cuff left behind, inform the patient, and document that.What we DON’T do:Biopsy lesions that are palpable or accessible via ultrasound- those usually go to ultrasound or pathPerform LPs under fluoro - that's neuroradiologyDaily Sign Out: Face-to-face sign-out must occur each day with the diagnostic radiology resident covering upper-level call that evening. This will occur at the beginning and the end of the daily shift.Handoff the pager at 5pm. You are still responsible for completing all your inpatient duties for that day and preparing for the following day.HOLDING/PRU: Outpatient consenting and post-procedure careTake notes on the printed outpatient schedule that is handed out during roundsThree things to do with each outpatient:1. Consent2. Pre-Procedure Orders:Orders: “Insert peripheral IV”Any labs you need to check order STATAntibiotics/ Pre-Meds: Nephrostomy tubes, PAE, etc. Verify with the attendingSIR Consensus Guidelines for Antibiotic Prophylaxis sets: “VIR – Pre Procedure” – Click the required sections regarding why they do not need DVT ppx (“Patient ambulatory/ fully mobile”)3. H&P: Including airway assessment (w/ Mallampati) and ASA scorePeds general anesthesia patients: Consent in Children’s PCS/PACUMonitor post procedure for complications. Follow up on CXR for thoracentesis, etc.Discharge patients home with appropriate follow up, medications (abx or pain meds) and medical suppliesPost-Procedure tab Orders: “Discharge patient” Medication Reconciliation (will need to go through prior to giving any new meds)Flushes – easier to hand-write the Rx.Leave at 5pm if all your work is complete. Any patients staying overnight in PRU should be checked out to the upper level on call/swing shift that is taking the inpatient pager. LIST RUNNING:Purpose:Review the outpatient/inpatients images & historyClarify procedural orders for appropriatenessVerify pre-procedural important info (allergies, labs, side, site, premeds needed, where to prep, supplies needed, anesthesia?, etc)How to do it correctly: Prepare the inpatient list the night before. The outpatient list can be done early, but you will need to check the night before to make sure it has not changed. Some people make templates on the computer and some hand-write the list. It’s up to you how you want to do it.Remote Epic/Impax Access (to work from home): csg.unch.unc.eduArrive a few min early to load the list and be ready to start at 0700.Run the inpatient list first, outpatient second.Adding images to PACS:You will use two separate lists/buckets for the inpatient and outpatient list (for the date you are running the list)VIR Inpatient Usually patients are sorted alphabetically by last nameVIR OutpatientAdd patient’s IN ORDER by their appointment timeClick “sort by added date” to sort the list in that orderAdd pertinent, recent images to the caseLines – most recent CXRSinograms – Prior sinogram, drain placement, or if they had a recent CTG/J/GJ tube exchanges – Last exchange or placementBiopsy – CT or US of what is being biopsied.Any previous VIR procedure, rmation Needed for Every Case:Brief Patient History/Assessment and Indication for the ProcedureEx: “Ms. Smith is a 52 yo F with history of metastatic breast cancer, here today for single lumen port placement for chemotherapy.”AllergiesContrast, Abx, Latex are the most important. If they are allergic to contrast, what type of allergy? If anaphylaxis, oral premeds should be taken, or other type of allergy this combo works:Solumedrol 125mg IV 1 hr priorBenadryl 50mg IV 1 hr priorLabs: Important for most, but not all procedures.Creatinine: (PICCs and contrast) <1.8. If they have an AKI or Cr is trending up.Platelets: > 50 for ports, tunneled lines, paras, thoras, arteriograms, perc liver biopsies, perc mass biopsies. Not so much a concern for nontunneled lines, HD fistulograms/shuntograms, sinograms, filter placements, transjug liver biopsies, PICC linesINR: < 1.5 for ports, tunneled lines, paras, thoras, arteriograms, perc liver biopsies, perc mass biopsies. (Not so much a concern for nontunneled lines, HD fistulograms/shuntograms, sinograms, filter placements, transjug liver biopsies, PICC lines)Anticoagulation:SIR Consensus Guidelines on Anticoagulation: with the VASC1 attending how long they would like the anticoagulation to be heldVerify with the patient or nurse how long it has been heldProphylactic heparin is okList of anticoagulants and required time to be held is in PRUList Pearls:For ports, go opposite the side of their breast/lung cancer or enlarged lymph nodesKnow if it's a dialysis graft or a fistulaKnow if the G tube is for venting or for feedsFilter removals need PVLs before filter removal if they are not on anticoagulationCANNOT do a percutaneous liver biopsy if the patient has ascites or is coagulopathicCan do transjugular. If they need portal venous pressures, then we do TJ.GENERAL VIR INFO/ TIPS:You can copy the H&P and Brief Procedure Note templates from an upper levelWhen on Inpatient, the “Patient Lists” tab is a much easier way to search for inpatients by last name, without having to look up the MRN each time. You can make your own list for VIR and add the patients to the list for quick reference. See the annotated campus map on Google drive for how to find all the different unitsConsent:Discuss indications, benefits, and alternatives for the procedureDiscuss risks of the procedure:For ALL procedures: Bleeding, infection, damage to adjacent structuresProcedure specific risks, for example:Thoracentesis PneumothoraxVerify Code Status If they are DNR/DNI, will it be continued or suspended during the procedure?Will the patient accept a blood transfusion if necessary?Consent Form:To print consent form: Patient Station OR Patient Lists Type in patient name/ MRN Summary Procedural Consent Choose English or SpanishBe as specific as possible on the consent form and avoid acronyms (i.e. "PICC" should be "peripherally inserted central catheter, single lumen")MUST INCLUDE “… with moderate sedation” in your consent for procedures that may need moderate sedation.For sinograms: Consent form should read “Sinogram with possible drain removal, exchange, or manipulation and possible moderate sedation”.If consent if from anyone other than the patient (phone or family at bedside) or through the Spanish interpreter it MUST be witnessed at the time of consentPlace consent in the chart or with their card on the inpatient boardBest to have floor nurse witness the consentConsultsHandling pages and phone calls: "We can do this procedure and will get to it as soon as possible. I can't guarantee it will be today, but we will try our best."Things to ask the primary team:Labs ok? INR, platelets – for most proceduresCr – for PICCs or anything that requires contrastBlood cultures – for any tunneled lines, including Aspira drains and PICCs (technically our policy per Burke is neg blood cx x 48 hrs for PICCs)Most recently drawn blood cultures MUST be negative x 48 hrs. If they are pending or positive, you can offer them a non-tunneled line or they can wait until the cultures are negative. Discuss with the team, depends on urgency of access.Is the patient consentable? If not, who is the POA/ emergency contact?Can also check in the chart, under Demographics Emergency ContactUrgency of the procedure?Patients that need HD, PLEX, or chemotherapy todayPatients without vascular access that are decompensatingIs the patient NPO? (if they may have the procedure that day)Verify orderHow many lumens? (see discussion on Lines below)Single, Dual, TripleTunneled or non-tunneled line?The team usually has no idea what this means, or what the types of lines mean. Ask how long they need the line, and what it will be used for.Verify labs (see discussion above)Do they want labs sent? (For drains, thoracentesis, paracentesis, etc)Ask them to place the orders – we have to place the orders if they don’t Portal pressures for transjugular liver biopsies?Central Venous AccessTwo Main Divisions: Tunneled vs. Non-TunneledTunneled Lines: (Moderate Sedation – NPO). Pertinent labs: platelets, INR, blood cx)Port: SL or DL, depends on chemotherapy regimen and oncologist preferencePowerline: SL or DL. Usually patients going home with antibiotics or home ionotropes.Tunneled HD catheters: For long-term HDHickman (triple lumen catheter): Usually cancer patientsApheresis catheters: PLEX or Stem cell transplant patientsNon-Tunneled Lines: (No sedation)PICC Lines – SL or DL (also need to check Cr)Non-tunneled HD catheters – Will likely not go home on HD, or have positive/pending blood cultures. Can convert to perm cath laters (“Temp to Perm”)Non-Tunneled TLCs (“Dixon Lines”) – Usually cancer patients or MICU patients on pressors, etc.How many lumens? Single LumenIf they only need one thing, like long-term antibiotics.Dual LumenIf they need two things that will run at the same time (ex. Chemo + antibiotics)Specific leukemia/lymphoma chemotherapies will need DLIf they need TPNTriple LumenUsually for cancer patientsProcedure Log:Must keep an up-to-date procedure log during this rotationSee Procedure Log Template on Google driveAn updated copy of your VIR procedure log should be uploaded to your myRSNA resident learing portfolio as well. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download