fluoroscopy for the radiologic technologist

Fluoroscopy for the Technologist

Alisha Anderson, RT(R), BSRSSt. Mary-Corwin Medical Center – Pueblo, Colorado

Midwestern State University, Wichita Falls, Texas

General ConsiderationsThe Radiologic Technologist’s Role

Contrast (Non-Injectable)

Barium◦ Available in different densities

◦ Contraindicated if perforation is suspected

◦ Must use 100kVp technique to penetrate

Iodinated Contrast Media◦ Gastrografin, Cystografin, Sinografin

◦ Appropriate if perforation is suspected, or if surgery is anticipated

◦ No increase in kVp technique required

Air◦ “Negative” contrast media

◦ Enhances lumen contours of GI tract

Injectable Contrast

All vial tops must be swabbed with alcohol wipe and have expiration date checked!

Iodinated Contrast◦ Isovue is the most common

Comes in different densities◦ Myelography requires lower density, preservative-free

Appropriate contrast will have an “M” after the density

May be used intravascular, intraarticular, intrathecal Important to assess patient allergies

◦ Contrast reactions more likely with IV injections

Non-iodinated Contrast◦ Gadolinium used for MRI studies

May be substituted if patient is allergic to iodinated contrast material for joint injections

General Considerations

Question pregnancy status Question allergies Question use of blood thinners Evaluate patient’s ability to comply Evaluate appropriateness of exam Consider contraindications of exam Give general exam description to patient

◦ Do not go into technical aspects of procedure

◦ Radiologist/RA will fully consent patient

Communicate pertinent history to radiologist/RA

Provide discharge instructions to patient

Common ProceduresHistory, Contraindications, Supplies, Procedure, Plain Films

Video FluoroscopyModified Barium Swallow, Swallowing Function Test

Indications & Patient History

• Aspiration (coughing/choking during swallowing)• Difficulty swallowing liquids or solids• Sensation of blockage or discomfort in the throat or

retrosternal region

• Relevant History• Stroke• Trauma (injury, previous radiation treatment)• Duration of difficulty swallowing• Consistencies which are difficult for patient

Contraindications

• Inability to comply with exam• Lowered level of consciousness• Ability to follow instructions

• Physical Contraindications• Patient size (may consider using C-Arm)• Recent Hip/Pelvis Fracture

• Wrong Exam• Patient does not have difficulty with swallowing

The ordering provider may accidentally orderthe incorrect exam (MBS vs. Esophagram)

Supplies

• Speech Pathologist will mix contrast materials• CD or DVD to record exam• Patient stickers to label disc• Lead shielding for all personnel in room• Vess chair• Gown to protect patient clothes• Washcloth to clean patient after exam

Procedure

Focuses on the oral cavity, pharynx, and cervical esophagus

• Move patient to Vess chair• Far right-side of chair, next to fluoro table• Secure with “seatbelts” if necessary

• Cover outpatient’s clothing with gown• Start recording disc when staff is ready to begin• Clean up patient & transfer out of Vess chair• Finalize disc when study is completed

• Remember to label disc appropriately

Plain Films & Discharge Instructions

Generally, no plain films are required

Speech Pathologist with give patient relevant discharge instructions(appropriate consistencies, diet restrictions)

Barium SwallowEsophagram


• Non-cardiac causes of chest pain• Symptomatic or suspected gastroesophageal reflux• Esophageal spasm or tumor• Suspected tear following an endoscopic dilatation

• Relevant History• Hiatal hernia• GERD• Pain• Difficulty swallowing• Trauma (injury, previous radiation treatment)• Duration of any symptoms

Contraindications

• Recent esophageal or gastric surgery• Barium should NOT be used• Gastrografin is a safer alternative

• Inability to stand/bear weight• May be able to complete with table in

horizontal/tilted position

• Wrong Exam• Patient primarily has difficulty swallowing

The ordering provider may accidentally orderthe incorrect exam (Esophagram vs. MBS)

Supplies

• Gas crystals• Gas drops• Glass of water• Thick and/or thin Barium • Gastrografin (if indicated)• 13mm Barium tablet• Straw• Cups for contrast agents• Lead shielding for all personnel

in room

Procedure

Focuses on the esophagus and its entry into the stomach. This may include an evaluation of the swallowing

mechanism with liquid consistencies

• Attach footboard & stand up fluoroscopy table• Change patient in to gown (nothing from waist up)• Set up table with supplies• Mix Barium according to directions (just before exam)• Stand patient with back against fluoroscopy table• Assist radiologist with procedure

• Holding contrast• Providing patient with pillow• Helping patient follow procedural instructions

• Take any overhead images per radiologist


• Drinking Esophagus• Patient RAO on table• Have patient begin drinking Barium• Keep drinking while taking esophagus image• Remember to use 100kVp if using Barium

• “High Abdomen”• Plain abdominal film centered higher to include the

contrast-filled stomach• Remember to use 100kVp if using Barium

• Remind patient to drink plenty of liquids to flush contrast from system

• Stools may have whitish color if Barium was used

Upper GIEsophagus, Stomach, Duodenum


• Suspected ulcer, hiatal hernia• Gastroesophageal reflux / pain• Dyspepsia, nausea, vomiting• Signs or symptoms of upper GI bleeding• Anemia or weight loss• Evaluation of bariatric surgery or device (gastric bypass,

LapBand, gastric sleeve, etc.)

• Relevant History• Duration of symptoms (any listed above, all GI

symptoms described by patient)• Previous surgeries• Trauma (injury, previous radiation treatment)• History described in the “Esophagram” section

Contraindications

• Patient has eaten• Radiologist will determine if study should

continue

• Recent esophageal or gastric surgery• Barium should NOT be used• Gastrografin is a safer alternative

• Inability to stand/bear weight• May be able to complete with table in

horizontal/tilted position

Supplies

• Gas crystals• Gas drops• Glass of water• Thick and/or thin Barium • Gastrografin (if indicated)• 13mm Barium tablet• Straw• Cups for contrast agents• Lead shielding for all personnel in

room

Procedure

Focuses on the esophagus, stomach, and duodenum.

• Attach footboard & stand up fluoroscopy table• Change patient in to a gown• Set up table with supplies• Mix Barium according to directions (just before exam)• Stand patient with back against fluoroscopy table• Assist radiologist with procedure

• Holding contrast• Providing patient with pillow• Helping patient follow procedural instructions

• Take any overhead images per radiologist


• Drinking Esophagus• Patient RAO on table• Have patient begin drinking Barium• Keep drinking while taking esophagus image• Remember to use 100kVp if using Barium





Small Bowel Follow ThroughSBFT, Barium or Gastrografin


• Unspecified abdominal pain• Constipation, diarrhea, blood in stool• History of Chron Disease or unexplained anemia• Suspected small bowel obstruction

• Unable to eat, vomiting bowel contents, etc.

• Relevant History• Duration of symptoms (any GI symptoms)• Surgical history• Trauma (injury, radiation therapy)• Presence of nasogastric tube

Contraindications

• Patient has eaten• Radiologist will determine if study should

continue

• BARIUM IS NOT ALWAYS THE MOST APPROPRIATE CONTRAST MEDIA FOR A SBFT!

• Reasons to use Gastrografin:• Recent bowel or gastric surgery• Strong suspicion of small bowel obstruction

with impending surgical intervention• Known or suspected bowel perforation• Presence of a nasogastric tube

Supplies

• 400-600 mL of thin Barium or Gastrografin• Straw, cups• Ice water• Emesis basin• Hour markers for plain films• Paper/white board to record when next film is due• If using NG tube for contrast administration:

• 60mL syringe, necessary adapters• Water to flush tube after administration

• Lead shielding for all personnel in room

ProcedureFocuses on the small bowel from the ligament of Treitz to

the ileocecal valve.

• Take a scout film if patient has not had a recent KUB• After radiologist views film, administer contrast

• Patient compliance is key to this procedure, you may have to “coach” them through drinking contrast

• Inform them that the contrast does not taste good, but try not to “poison the well” with your description

• Have them put the straw in the back of their mouth, or try holding their nose and drink from cup

• They need to try not to vomit the contrast• If using NG tube, attach adapter to tube, administer

contrast, refilling syringe until all contrast is in. Flush with plain water to clear tube of contrast.• If the patient goes back up to the floor before

study is completed, communicate to nurse DO NOT hook tube back up to suction

Procedure (con’t.)

• Take a “High Abdomen” film initially to include the contrast-filled stomach

• Continue taking films (“high abdomen”, KUB) as directed by the radiologist until the contrast reaches the ileocecalvalve• Record the time (clock time & time since contrast

administration) on films and on paper/white board• Explain to the patient that the study time may vary

• If patient condition allows, and radiologist agrees:• Lie on right side to encourage stomach emptying• Walk around to encourage contrast movement• Drink a glass of ice water

• Once contrast reaches ileocecal valve, the radiologist will spot the patient using fluoroscopy




• KUB• May require shooting films landscape or in

“quadrants” if patient is large• Remember to use 100kVp if using Barium


• Stools may have whitish color if Barium was used• If NG tube is used, it should NOT be reconnected to

suction until the study has been completed

Barium EnemaSingle or Double Contrast, Barium or Gastrografin

Indications & Patient History• Double Contrast Barium Enema is best study to

demonstrate colonic pathophysiology if not contraindicated

• General Indications • Change in bowel habits• Inflammatory bowel disease• Incomplete colonoscopy• Rectal bleeding• Diverticulitis or polyps

• Single Contrast Indications• Colonic obstruction• Colonic perforation (non-Barium study)• Poor rectal tone/unable to roll 360o

• Relevant History• Duration of symptoms (any GI symptoms)• Surgical history• Trauma (injury, radiation therapy)• History of known fistula

Contraindications

• BARIUM IS NOT ALWAYS THE MOST APPROPRIATE CONTRAST MEDIA FOR A BARUIM ENEMA!

• Reasons to use Gastrografin:• Suspected colonic obstruction likely requiring surgical

intervention• Suspected or known colonic perforation• Recent bowel surgery, biopsy, polypectomy

• Incomplete bowel preparation as judged by scout KUB• Unless the study is emergent, the BE should be

postponed until adequate bowl preparation is complete

• Recent bowel surgery, biopsy, polypectomy• Unless the study is emergent, the BE should be

postponed for 7 days following interventions

Supplies

• Enema bag• Tubing• IV pole• Enema tip• Lubricant• Tape• Insufflator Bulb• Hemostat• Contrast

• Lower GI Barium • Gastrografin/Cystografin

• Table pad under patient• Extra towels, washcloths• Lead shielding for all personnel

in room

Procedure

• Change patient into gown (absolutely no other clothing should be worn, including socks)

• Take scout KUB and show to radiologist• Once cleared by radiologist, insert enema tip:

• Have patient lie in Simms position• Lubricate enema tip• Have patient take deep breath, exhale as tip is inserted• Insert tip anteriorly, then posteriorly to follow rectal curve• Inflate balloon, no more than two pumps

• If balloon is contraindicated, tape tip in place• Place gentle traction on tip to ensure it is secured

• Under direction of radiologist, unclamp the tubing, raise or lower enema bag as needed

• Aid patient in moving during study as per radiologist• Take overhead films per radiologist• Remove enema tip, help patient to commode to evacuate


• Remember to use 100kVp if barium is used!

• Cross-table lateral rectum in prone position• Cross-table left lateral decubitus abdomen• Cross-table right lateral decubitus abdomen• Rectosigmoid colon (tube 30o cephalic with patient prone)• KUB with patient prone



Joint Injection/AspirationMRI or CT Arthrogram, Pain Management

Indications & Patient History• Athrocentesis Indications

• Determine joint infection vs. inflammation

• Arthrogram Indications• Joint pain, swelling, limited range of motion

• Shoulder – suspected labral or roator cuff tear• Hip – suspected labral tear

• Generally, MRI arthrogram is preferred, may have CT arthrogram if MRI is contraindicated

• Joint Injection (Pain Management) Indications• Usually ordered by orthopedic surgeon• Painful, arthritic joint as evidenced by imaging studies

• Relevant history• Trauma, mechanism of injury• Duration of symptoms• Surgical history at affected joint• Allergy to contrast material, local anesthetic medications• Use of blood thinners• For pain management injections, history of diabetes

Contraindications

• Recent use of blood thinning medications• Aspirin, Coumadin, Plavix, etc.

• Radiologist will determine whether to cancel study• Allergy to iodinated contrast material

• Patient may need to be pre-medicated• Radiologist may opt to use gadolinium only

• True gadolinium allergy is very rare• Allergy to local anesthetic medications

• Lidocaine, Xylocaine, Marcaine, Bupivicaine, etc.• Radiologist will determine whether to continue

study without local anesthetic• For pain management injections

• Allergy to corticosteroids• Diabetic patient (may use lower dose corticosteroid)

Supplies• Surgeon’s sterile gloves• Marker and hemostat for radiologist• Injection tray

• Lidocaine• Syringes for medication and contrast• Spinal Needle• Tubing• Vials for athrocentesis• Drapes• Skin prep soap

• Larger spinal needle (if patient is large)• Additional syringes/needles as needed• Contrast

• Iodinated for all studies• Gadolinium & saline for MRI arthrograms

• Pain Management Medications• Local anesthetic, corticosteroid

• Lead shielding for all personnel in room• Invasive Procedure, hat and mask required

Procedure

• Change patient according to joint being studied• Take scout images if none from the previous month are

available (or per facility protocol)• Show films to radiologist• Set up sterile field with supplies• Radiologist will assist in positioning patient for procedure• Clean the tops of each vial and hold medication for radiologist

• State medication type and expiration date• Provide additional supplies to radiologist as needed• Help patient follow radiologist instructions during procedure• Clean injection site and dress appropriately• If patient is going to MRI or CT, gather belongings and take

patient to other modality once exam completed


• Usually, no plain films are needed unless an arthrogramwas performed under general diagnostic x-ray only (no CT or MRI athrography to follow)

• Unusual drainage or sign of infection should be reported• Fever above 100oF should be reported to physician

following any injection/aspiration• Patient can resume blood thinner medications same day

• Pain management• The corticosteroid may take up to 3-4 days to take

full effect. The patient should be informed that the numbing medicine may wear off and the old pain may return before the steroid takes effect

HysterosalpingogramDiagnostic/Therpeutic & Essure Coil Confirmation


• Identify obstructed fallopian tubes• Ensure proper Essure coil device placement• To visualize structural abnormality of uterus or fallopian tubes

• Relevant history• Number of pregnancies and live births• Date of last menstrual period• No unprotected sexual intercourse since LMP

• Verifies patient is not pregnant• Reason for exam (fertility, Essure confirmation)• Any known structural abnormality or fistula

Contraindications

• CHANCE OF PREGNANCY IS AN ABSOLUTE CONTRAINDICATION!

• Iodine allergy• Radiologist will determine if patient needs to be

pre-medicated

Supplies

• Sterile surgeon’s gloves• Spotlight• Stirrups• HSG Tray

• Speculum• Lubricant• Betadine & swabs• Drapes• Cervical cannula• Uterine sound

• Additional drapes, speculum• Contrast (Sinografin, Isovue)• Washcloth and sanitary pad• Lead shields for all personnel in room• Invasive Procedure, hat and mask required

Procedure

Evaluates the endometrial cavity and patency of fallopian tubes

• Attach stirrups to table, remove pad and place disposable drape under patient

• Change patient into gown (nothing from waist down) & have them empty bladder

• Take a scout bladder shot• Show film to radiologist• Assist patient moving to end of table, place feet in stirrups• Radiologist will cannulate the cervix• Help patient move up the table for imaging portion of exam• Aid patient in following radiologist instructions• Radiologist will remove cannula• Help patient off table. Have them try to empty bladder.• Take another bladder shot & show it to the radiologist


• Scout bladder film• Post-Void bladder film

• Any fever above 100oF, new or persistent pain, abnormal bleeding should be reported to physician

• Some cramping following the procedure is normal, patients may take acetaminophen or ibuprofen

Lumbar PunctureDiagnostic/Therapeutic, Myelography


• Lumbar Puncture indications• Suspected meningitis, multiple sclerosis, CNS infection,

subarachnoid hemorrhage• Intrathecal chemotherapy treatment

• Myelography indications• Demonstrate a CSF leak• Evaluation of radiculopathy• Spinal stenosis• Surgical/radiation therapy planning

• Relevant history• Duration of symptoms

• Fever, altered mental status, pain, trauma• Abnormal brain MRI (Multiple Sclerosis)• Past surgical history to the spine• Emergent LPs: may be unable to obtain full history

Contraindications

• Lumbar puncture• No absolute contraindications to LP

• Procedure is usually emergent to diagnose infection, therefore it may be performed under a variety of patient conditions

• If non-emergent, may be rescheduled until patient holds blood thinners

• Myelography• Allergy to contrast media

• Radiologist will determine if patient should be pre-medicated

• Known increased intracranial pressure• Evidence of bleeding disorder• Generalized septicemia• Grossly bloody spinal tap• Infection at proposed puncture site• Pregnancy• Use of anticoagulant medications

Supplies

• Sterile surgeon’s gloves• Marker and hemostat for radiologist• Lumbar pucture / Myelogram Tray

• Betadine• Drapes• Lidocaine• Spinal needle• Various syringes/needles/tubing• Collection tubes

• Additional spinal needles• Additional syringes/needles as needed• Patient labels for tubes (diagnostic puncture only)• Biohazard lab bag (DX and Chemo with lab order only)• Contrast Isovue 200-M or 300-M (Myelogram only)• Chemotherapy drug (intrathecal chemo treatment only)• Lead shielding for all personnel in room• Invasive Procedure, hat and mask required

Procedure

• Attach foot board to table• Change patient in to a gown unless clothing is loose• Set up sterile field for radiologist• Lie patient prone on table• Radiologist will perform puncture

• Diagnostic: take tubes of CSF from radiologist & label• Myelogram: hold contrast for radiologist• Chemo: hand sterile syringe of medication to radiologist

• Encourage patient to remain still during procedure• If drawing fluid off, radiologist will tilt table head up• If performing myelography, radiologist will tilt table head down

• Cervical myelography: have patient extend neck, look forward, resting chin on table

• Clean puncture site, apply appropriate dressing• If CT myelography is to be performed, take patient to CT while

lying prone, keeping neck extended


• X-table lateral of the spinal region under study• Both RAO and LAO obliques• Bilateral AP decubitus projections

• Patient MUST remain lying down flat for the next 4 hours• Patient should drink plenty of water• Development of new fever above 100oF, unusual bleeding,

or severe headache should be reported to physician• If anticoagulants have been withheld, they can be

restarted that same day

Intravenous UrographyIntravenous Pyelogram (IVP/IVU)

Indications & Patient History• Pyelonephritis• Hematuria• Assess renal function (kidney donor, cancer of GU tract)

• Relevant history• Duration of symptoms• Pain, hematuria, history of stones, infection• Surgical history• Known anatomical variations• History of diabetes• Allergy to contrast material (VERY IMPORTANT)• Lab values (VERY IMPORTANT)

• Must check serum creatinine (0.5-1.5mg/dL) and BUN (7-20mg/dL) levels

• Use levels to calculate GFR (mL/min/1.73m2):• >60 safe to inject (>90 normal)• 45-60 low risk• 30-44 moderate risk• <30 high risk

Contraindications

• GFR >30 is indicative of severe renal insufficiency• Radiologist will make ultimate determination based on

lab values

• Allergy to contrast media • Radiologist will make determination to terminate

study or pre-medicate patient• REMEMBER: ALLERGIC REACTION IS MUCH MORE

LIKELY WITH IV CONTRAST ADMINISTRATION!

• Diabetic currently taking Metformin• Stop taking metformin 24-48 hours before procedure

Supplies

• IV start kit• Angiocath needle (18-20G preferred)• Contrast media (usually Isovue-370)• IV connection tubing• 60mL syringe• 18G draw needle• Calipers• Film markers (minutes, scout, post-void)

ProcedureAssesses the function of the kidneys with demonstration of renal parenchyma,

pelves, calyces, and filling/emptying of the bladder.While this is procedure usually falls under the category of fluoroscopy and is

directed by a radiologist, the technologist essentially “performs” the procedure.

• Change patient in to gown and empty bladder• Take scout KUB & show film to radiologist• CHECK LAB VALUES AND REPORT THEM TO RADIOLOGIST• Measure patient with calipers to determine tomography slices• Draw up contrast into syringe; attach & flush tubing• Start IV line, inject contrast

• Inform patient they may experience a warm, flushed feeling

• Contrast reactions usually occur in the first 5 minutes• Take 0 minute “nephrogram” image• Take tomos or plain KUBs at 5,10,15 minutes as directed by a

radiologist (prone or oblique films may be required)• At radiologists direction, have patient empty the bladder• Take a post-void plain film, show to radiologist• Discontinue IV line


• Scout KUB• Nephrogram (10x12 centered to kidneys)• KUBs or tomograms• Post void KUB or bladder shot

• Delayed contrast reactions are very rare• If patient develops itching, difficulty breathing, etc. they

should contact the ER• Metformin may be resumed 24 hours after procedure• Patients should drink plenty of fluids (water, juice) to help

flush contrast out of GU tract

CystographyVoiding Cystourethrogram (VCUG), Cystogram


• Vesicoureteral reflux• Suspected posterior urethral valves in male• Evaluate causes of hematuria• Suspected leak after pelvic surgery/injury• Detect bladder polyps or tumors• Follow-up of an abnormality seen on US or CT

• Relevant history• Duration of symptoms (any GU symptoms)• Allergy to contrast media• Known anatomical variations• Trauma (injury, radiation therapy)• Surgical history

Contraindications

• Allergy to contrast media• Radiologist will determine to proceed or pre-medicate

the patient

• Inability to catheterize patient

• If ordered with sedation, anesthesia consult is required• This is more common with pediatric patients

Supplies

• Catheterization tray• Tape or Stat-Lok• Cystografin (two bottles)• 60mL syringe• Large-bore tubing• IV pole• Male or Female Urinal (VCUG only)• Lead shielding for all personnel in room

Procedure

Focuses on bladder shape, size, urethra and vesicoureteral reflux.

• Change patient in to gown, empty bladder• Attach footboard to table, remove pad, lay out disposable pad• Take scout KUB or bladder shot & show to radiologist• Hang Cystografin bottles, spike bottle with tubing & flush• Fill 60mL syringe with air and attach to Tubing• Catheterize patient, draining any remaining urine• Secure catheter with Stat-Lok or tape• Connect tubing to catheter• Under direction of radiologist, unclamp the tubing• Aid the patient in following the radiologist’s instructions• Remove the catheter• VCUG: give patient the urinal & help them follow instructions,

when finished voiding, take urinal• Help patient off table to commode, empty bladder• Take post-void KUB or bladder shot


• Scout KUB or bladder shot• Post-void KUB or bladder shot

• Patients should drink plenty of fluids (water, juice) to help flush contrast out of GU tract

Questions?Thank you

fluoroscopy for the radiologic technologist

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