Interventional Radiology Nursing Guide

IR Fundamentals & Imaging Guidance

What is Interventional Radiology?

Interventional Radiology (IR) is a medical subspecialty that performs minimally invasive diagnostic and therapeutic procedures guided by real-time medical imaging. IR techniques avoid the need for open surgery, offering reduced recovery times, lower complication rates, and shorter hospital stays.

Imaging Modalities Used

Fluoroscopy: Most common; real-time X-ray for vascular work
Ultrasound: Vascular access, drainage, biopsies — no radiation
CT: Ablation, biopsy, drainage of deep structures
MRI: Soft tissue detail; used in MR-guided procedures

Key IR Settings

Dedicated IR suite (angio suite)
Hybrid OR (combined IR + surgical)
CT/ultrasound procedure rooms
Emergency IR (24/7 availability in major GCC centres)

Radiation Safety

ALARA Principle

AS LOW AS REASONABLY ACHIEVABLE

Time: Minimise time in radiation field; step back when not required
Distance: Inverse square law — doubling distance reduces dose to ¼
Shielding: Lead aprons, thyroid shields, lead glasses, mobile screens
Use pulse fluoroscopy (not continuous)
Collimate beam to area of interest
Last-image-hold feature — avoids unnecessary screening

Personal Protective Equipment

Lead apron: 0.35–0.5mm lead equivalent; worn for all fluoroscopy
Thyroid collar: Mandatory — thyroid highly radiosensitive
Lead glasses: Reduce lens dose; protect against cataracts
Lead gloves: When hands near primary beam
Dosimetry badge: Worn at collar level (outside apron) monthly review
Second badge: Under apron at waist to estimate effective dose

⚠ Annual whole-body radiation limit for occupational workers: 20 mSv/year (averaged over 5 years, max 50 mSv in any single year) per ICRP recommendations.

Contrast Agents

Iodinated Contrast Media (ICM)

Classification & Routes

LOCM (non-ionic low-osmolality): Preferred — iopamidol, iohexol, iopromide
HOCM (ionic high-osmolality): Avoid in at-risk patients
IOCM (iso-osmolar): Iodixanol — best renal profile
Routes: IV (CT/IVU), intra-arterial (angiography), intrathecal (iso-osmolar only)

Contrast-Induced Nephropathy (CIN)

Rise in serum creatinine ≥25% or ≥44 µmol/L within 48–72h of contrast
High risk: eGFR <30 mL/min/1.73m²
Moderate risk: eGFR 30–44 with diabetes or other risk factors
Metformin: Hold 48h post-contrast if eGFR <45 (lactic acidosis risk)
Hydration: IV 0.9% NaCl or sodium bicarbonate pre & post (cornerstone prevention)
N-acetylcysteine (NAC): Evidence debated — some centres still use 600mg BD
Use minimum volume of contrast; consider CO₂ angiography in severe CKD

Gadolinium-Based Contrast (MRI)

Used for MRI vascular and soft-tissue enhancement
Nephrogenic Systemic Fibrosis (NSF): Rare but serious; associated with linear gadolinium agents in severe renal failure
eGFR <30: Avoid or use macrocyclic agents only (gadobutrol, gadoterate)
Linear agents (gadopentetate) contraindicated in eGFR <30
NSF: irreversible fibrosis of skin, joints, internal organs
No dialysis shortcut — gadolinium dialysis clearance not preventive

Contrast Allergy Management

Reaction Classification

Mild: Nausea, flushing, urticaria, mild itching
Moderate: Bronchospasm, angioedema, hypotension
Severe/Anaphylaxis: Cardiovascular collapse, loss of consciousness

Pre-Medication Protocol (Previous Reaction)

Hydrocortisone 200mg IV — 13h, 7h, and 1h before contrast
Chlorphenamine 10mg IV — 1h before
Oral prednisolone 50mg as alternative to IV hydrocortisone

🚨 Anaphylaxis in IR Suite: IM adrenaline 0.5mg (1:1000), call crash team, oxygen, IV access, supine, adrenaline infusion if refractory. Adrenaline auto-injector (EpiPen) should be immediately accessible.

Fluoroscopy & Ultrasound Guidance

Fluoroscopy Principles

Pulse fluoroscopy: X-ray emitted in pulses (7.5–15 fps) rather than continuously — major dose saving
Magnification: Increases patient dose; use judiciously
Collimation: Narrows beam to area of interest; reduces scatter
Angulation: Lateral/oblique views increase dose; minimise
Nurse position: >2m from X-ray tube; use mobile lead shield

Ultrasound Guidance

No ionising radiation — preferred for vascular access, drainage, biopsies
Techniques: In-plane (full needle visible) vs out-of-plane (cross-section)
Applications: CVC/arterial access, thoracentesis, paracentesis, soft tissue biopsy
Nursing: Sterile transducer sleeve + gel; confirm venous compressibility (veins compress, arteries do not)

Vascular Interventional Radiology

Angiography

Diagnostic Angiography

Catheter introduced via arterial access (usually femoral/radial)
Contrast injection under fluoroscopy to visualise vessels
Digital Subtraction Angiography (DSA): bones subtracted, vessels highlighted
Indications: PAD evaluation, aneurysm sizing, bleeding source identification

Pre-Procedure Nursing

Verify consent, NPO status, allergies, medications
Check FBC, coagulation screen (INR, APTT), renal function (eGFR, creatinine)
Access site preparation: bilateral groin/radial hair removal if required
IV access patent (minimum 18G)
Baseline limb pulses documented
Pre-medication contrast allergy if history

Angioplasty & Stenting

Peripheral Arterial Disease (PAD)

PTA: Balloon dilation; Stenting: Bare metal or drug-eluting stent
Sites: iliac, femoral-popliteal, tibial arteries
Post-procedure: Hourly limb perfusion — 6 Ps (Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Poikilothermia)
Antiplatelet therapy post-stent (aspirin ± clopidogrel); Doppler USS if concerns

Renal Artery & Carotid Stenting

Renal artery stenting: Renovascular hypertension; post-op: BP, UO, renal function 24–48h
Carotid stenting (CAS): Embolic protection device required
Post-CAS: Hourly neuro obs (GCS, limb power, speech) ≥4h; BP target 120–160 mmHg
Bradycardia common (carotid sinus pressure) — atropine available

Embolisation Procedures

Uterine Fibroid Embolisation (UFE)

Procedure Overview

Bilateral uterine artery embolisation using microspheres/PVA particles
Alternative to hysterectomy/myomectomy for symptomatic fibroids
Common in GCC population — high fibroid prevalence
Same-day or overnight admission

Post-Embolisation Nursing Care

Pelvic/uterine cramping: Expected; multimodal analgesia (NSAID + opioid PCA)
Post-embolisation syndrome (PES): Fever, malaise, nausea 24–72h post — distinguish from infection
Regular temperature, WBC monitoring
Vaginal discharge/fibroid expulsion: patient education
Urinary retention possible — catheter as needed
Discharge criteria: pain controlled on oral analgesia, tolerating fluids

GI & Trauma Haemorrhage Embolisation

GI haemorrhage: Emergency embolisation when endoscopy fails; coil/gelfoam/glue agents
Nursing: haemodynamic monitoring, blood products available, massive transfusion protocol; document Hb trend
Trauma: Splenic, hepatic, pelvic injuries — concurrent ICU care; monitor for re-bleed (tachycardia, hypotension, falling Hb)

IVC Filter

Indication: PE prophylaxis when anticoagulation contraindicated
Retrievable vs permanent: Retrieve when anticoagulation becomes safe (window 1–6 months)
Access: right jugular or femoral vein
Post-procedure: Access site check, limb swelling, DVT surveillance

TIPS Procedure

Trans-jugular Intrahepatic Portosystemic Shunt (TIPS)

Indications & Procedure

Refractory variceal bleeding (oesophageal/gastric), refractory ascites, hepatic hydrothorax, Budd-Chiari
Jugular vein → hepatic vein → transhepatic needle → portal vein; stent creates portosystemic shunt
Target portal pressure gradient: <12 mmHg

Post-TIPS Nursing

Hepatic encephalopathy (HE): Key risk — hourly GCS, orientation, asterixis; serum ammonia
Lactulose ± rifaximin for HE prevention
LFTs, INR, U&E; Doppler USS at 24h (shunt patency)
Haemodynamic monitoring for haemoperitoneum

Thrombolysis (CDT)

Catheter-Directed Thrombolysis (CDT)

Indications & Agents

Extensive iliofemoral DVT (prevent post-thrombotic syndrome), massive/submassive PE
Urokinase: 100,000–200,000 IU/h; Alteplase: 0.5–1 mg/h CDT
Duration: 12–24h (DVT), 6–12h (PE)
Contraindications: Active bleeding, surgery <10 days, stroke/cranial trauma <3 months

Nursing During Infusion

Hourly bleed obs: Access site, neuro status, GI, haematuria
Fibrinogen 4–6 hourly — stop infusion if <100 mg/dL
APTT target 60–80 sec if heparin co-infusion; no IM injections
Separate IV access (not infusion limb); HOB 30°

Post-Procedure Access Site Care

Haemostasis & Post-Procedure Observations

Access Site	Haemostasis	Bed Rest	Key Obs
Femoral artery ≥6F	Manual 10–20 min or closure device (Angioseal/Perclose)	2–4h (device); 4–6h (manual)	Groin 15–30 min; distal pulses hourly
Femoral artery ≤5F	Manual 5–10 min	2–4h	Haematoma; DP/PT pulses
Radial artery	TR Band 2h	None required	Barbeau test; radial pulse
Femoral/jugular vein	Manual 5–10 min	2h (femoral); none (jugular)	Swelling, haematoma, airway (jugular)

Non-Vascular Interventional Radiology

Drainage Procedures

Abscess Drainage (CT/USS-guided)

Pigtail catheter (8–14F) under CT/USS — preferred over open surgery
Daily drain output (volume, colour, consistency); secure drain; flushing per IR protocol
Sepsis markers: temperature, WBC — improvement expected 48h
Remove drain: <10 mL/24h, afebrile, resolving on imaging

Thoracentesis (USS-guided)

Pleural fluid — diagnostic or therapeutic; sit leaning forward
Max drainage 1–1.5 L (re-expansion pulmonary oedema risk)
Post-procedure CXR within 1–4h; monitor SpO₂, pain, BP

Paracentesis (USS-guided)

LVP (>5L): albumin replacement 8g/L drained (beyond first 5L)
Monitor BP, HR, fluid balance; send MC&S, cytology, SAAG

Percutaneous Nephrostomy (PCN)

Indications: obstructive uropathy, urosepsis, malignant obstruction
Hourly urine output; post-obstructive diuresis (>200 mL/h) — replace 50% IV
Haematuria common first 24h; tube security (bag to thigh); temperature monitoring

Biliary Procedures

Percutaneous Transhepatic Cholangiography & Drainage (PTC/PTBD)

Types & Indications

PTC: Diagnostic — contrast to opacify biliary tree
External PTBD: Drain to bag; Internal-external: Spans stricture
Biliary stent: Permanent stent for malignant stricture
Indications: Obstructive jaundice (cholangiocarcinoma, pancreatic Ca), failed ERCP, benign strictures

Post-Procedure Nursing

Bile output: Colour (gold/green normal), volume 400–800 mL/24h; secure bag below drain
Cholangitis: High risk — prophylactic antibiotics (pip-taz or cipro + metro)
Temperature q4h; monitor Charcot's triad (fever + RUQ pain + jaundice)
LFTs/bilirubin trend — improvement expected 48–72h; skin care around site

🚨 Reynolds pentad (Charcot's triad + hypotension + confusion): escalate immediately, blood cultures, IV antibiotics, IV fluids, ICU consideration.

Image-Guided Biopsy

Percutaneous Biopsy Procedures

Biopsy Type	Guidance	Main Risk	Post-Procedure Observation
Liver (percutaneous)	USS / CT	Haemorrhage, biliary leak	4h obs: BP, HR, pain, Hb check; right lateral position 2h
Liver (trans-jugular)	Fluoroscopy	Haemorrhage (contained), arrhythmia	Cardiac monitoring 1h; jugular site check
Lung biopsy	CT	Pneumothorax (15–20%), haemoptysis	CXR at 1h and 4h; SpO₂; observe for haemoptysis
Renal biopsy	USS / CT	Haemorrhage, haematuria	Hourly urine for haematuria; BP/HR 4h; Hb
Bone biopsy	CT / fluoroscopy	Fracture, haemorrhage, infection	Pain, neurovascular obs of limb, wound check
Lymph node	USS / CT	Haemorrhage, nerve injury	Haematoma check, neuro observations

⚠ Lung biopsy pneumothorax: Small pneumothorax (<20%) may be observed. Large or symptomatic → chest drain. Always have small-bore drain kit available in CT room during lung biopsies.

Tumour Ablation

Radiofrequency, Microwave & Cryoablation

Modalities & Indications

RFA: Thermal (90–105°C); 3–5cm zone; liver/kidney/lung
MWA: Faster, larger zone; less heat sink effect; preferred near vessels
Cryoablation: Freeze-thaw (-40°C); ice ball visible on CT; near nerves/vessels
IRE: Non-thermal; near biliary/vascular structures
Indications: HCC ≤3cm (GCC priority), RCC <4cm, lung/bone metastases

Post-Ablation Syndrome & Monitoring

Fever 37.5–38.5°C for 1–5 days — cytokine release; self-limiting; paracetamol
Distinguish from infection: true sepsis = >38.5°C, rigors, rising WBC
Liver: LFTs 24–48h, biloma/abscess, INR
Renal: Urine output, haematuria, creatinine
Lung: SpO₂, CXR (pneumothorax, effusion)

Spine Procedures

Vertebroplasty & Kyphoplasty

Indications & Technique

Vertebral compression fractures (osteoporotic, malignant/metastatic)
Vertebroplasty: Percutaneous injection of PMMA cement into fractured vertebral body under fluoroscopy
Kyphoplasty: Balloon tamp inflated first to restore vertebral height → cement fill
Significant pain relief usually immediate

Post-Procedure Neurological Monitoring

Hourly neurological observations for 4h: lower limb power, sensation, reflexes
Cement leakage risk: Epidural (cord compression), foraminal (nerve root), venous (pulmonary cement embolism)
Report any new lower limb weakness, numbness, urinary/faecal incontinence immediately
Mobilise with physiotherapy within 2–4h if neurologically stable
Bone metastasis: concomitant radiotherapy planning often required

Sedation & Analgesia in IR

Conscious Sedation (Moderate Sedation)

Most IR procedures are performed under conscious sedation — a drug-induced depression of consciousness where the patient retains the ability to maintain a patent airway and respond purposefully to verbal commands.

Standard IR Combination

Midazolam: 0.02–0.05 mg/kg IV (titrate); onset 2–3 min; duration 30–60 min
Fentanyl: 1 mcg/kg IV (titrate); onset 1–2 min; duration 30–60 min

Additional Agents

Ketamine: Dissociative — paediatrics or painful procedures
Propofol: Deep sedation — anaesthetic involvement required
Dexmedetomidine: Alpha-2 agonist; cooperative sedation; minimal respiratory depression

Local Anaesthetic

Lignocaine plain: Max 3 mg/kg (absolute 200 mg)
Lignocaine + adrenaline 1:200,000: Max 7 mg/kg (absolute 500 mg)
LAST signs: Circumoral tingling, metallic taste, tinnitus, seizures, cardiovascular collapse
LAST treatment: Stop, call help, airway, Intralipid 20% 1.5 mL/kg IV bolus
Bupivacaine: longer duration; more cardiotoxic — lower safety margin

Intra-Procedure Monitoring

Monitoring During Sedation

Mandatory Monitoring

SpO₂: Continuous; oxygen delivery if <94%
Capnography (ETCO₂): Gold standard for respiratory depression detection; capnography detects hypoventilation before SpO₂ desaturates
ECG: Continuous 3/5-lead monitoring
NIBP: Every 5 minutes minimum
Level of consciousness: Verbal response, sedation scale

Ramsay Sedation Scale

Anxious/agitated

Cooperative, orientated, tranquil — ideal target

Responds to commands only

Brisk response to stimulation

Sluggish response — over-sedation

No response — emergency

Nursing Role During Sedation

Dedicated sedation nurse (not scrub nurse)
Continuous vital signs monitoring and documentation
Drug administration at IR physician direction
Early recognition of over-sedation
Emergency equipment checked and at hand: suction, airway adjuncts, reversal agents, crash trolley
Document: drug, dose, time, patient response for each administration

Reversal Agents

Flumazenil — Benzodiazepine Reversal

Dose: 0.2 mg IV over 15 sec; repeat 0.1 mg/min; max 1 mg
Half-life: 45–90 min — shorter than midazolam
Re-sedation risk: Flumazenil wears off first — monitor 1–2h post reversal
Caution: may precipitate withdrawal seizures in chronic benzodiazepine users

Naloxone — Opioid Reversal

Dose: 0.04–0.4 mg IV; repeat every 2–3 min; max 10 mg
Half-life: 30–90 min — multiple doses may be needed
Also reverses analgesia — provide alternative pain relief
Caution: opioid withdrawal, pulmonary oedema, tachyarrhythmia

Recovery After Sedation

Aldrete Score & Discharge Criteria

Modified Aldrete Score (max 10)

Activity: Move 4 limbs=2, 2=1, 0=0
Respiration: Deep breath=2, dyspnoeic=1, apnoeic=0
Circulation: BP ±20% pre=2, ±20–49%=1, >50%=0
Consciousness: Fully awake=2, arousable=1, not=0
SpO₂: ≥92% on air=2, O₂ needed=1, <90%=0

✓Score ≥9/10 = safe to discharge from recovery

Discharge Criteria (Day Case IR)

GCS at baseline — orientated, responds to name
Vital signs stable ≥30 min (within 20% baseline)
Ambulation at pre-procedure level
Nil nausea/vomiting — tolerating oral fluids
Pain NRS ≤3 on oral analgesia
Adult escort available; written instructions given

Pre-Procedure Assessment

Pre-IR Procedure Nursing Assessment

Essential Checks

Consent: Valid written consent verified
NPO: ≥6h solids / ≥2h clear fluids before sedation
Allergies: Contrast (type/severity), latex, drugs, anaesthetic agents
Pregnancy test: All women of reproductive age before fluoroscopy
Baseline: BP, HR, SpO₂, temp, weight (for drug dosing), GCS

Anticoagulation Management

Warfarin: Hold 5 days; INR <1.5 (high-bleed) or <2.0; LMWH bridge if high VTE risk
LMWH: Therapeutic hold 24h pre; prophylactic hold 12h pre
DOAC: Hold 24–48h (rivaroxaban/apixaban); 48h dabigatran (eGFR-guided)
Antiplatelet: Aspirin usually continued; clopidogrel hold 5–7 days if high-bleed risk

Laboratory Thresholds

Test	Target
INR	<1.5 (high-risk); <2.0 (low-risk)
Platelets	>50,000/µL (min); >100,000 preferred
Haemoglobin	>8 g/dL; transfuse if <7 g/dL
eGFR/Creatinine	<30 = high contrast risk
Fibrinogen	>1.5 g/L for thrombolysis

Time-Out (IR WHO Checklist)

Patient identity (name + DOB + ID band)
Procedure and site confirmed by whole team
Consent present and reviewed
Allergies communicated
Equipment/imaging available
Antibiotic prophylaxis given if required

Post-Procedure Complications

Access Site Complications

Groin Haematoma

Small haematoma: firm pressure, bed rest, mark border with pen, observe
Expanding haematoma: immediate pressure, escalate urgently
Retroperitoneal haematoma: Rare but dangerous — femoral access above inguinal ligament. Presents with: back/flank pain, hypotension, Hb drop WITHOUT visible groin swelling. Diagnosis: CT abdomen. Management: supportive/embolisation

Pseudoaneurysm (False Aneurysm)

Pulsatile swelling at femoral puncture site; bruit on auscultation
Diagnosis: Duplex USS Doppler (yin-yang sign on colour flow)
Management: USS-guided thrombin injection (ultrasound-guided compression less common now) or surgical repair
Risk factors: large sheath, inadequate compression, anticoagulation, hypertension

Contrast Reactions — Nursing Response

Reaction	Signs	Management
Mild	Flushing, nausea, urticaria	Monitor, antihistamine PO/IV, reassure
Moderate	Bronchospasm, angioedema, hypotension, tachycardia	Stop contrast, call for help, IV antihistamine, IV hydrocortisone, salbutamol nebuliser, IV fluid bolus
Severe — Anaphylaxis	Cardiovascular collapse, LOC, severe bronchospasm	Call crash team, IM adrenaline 0.5mg (1:1000), IV access, 1L fluid bolus, high-flow O₂, supine, CPR if arrest

Procedure-Specific Complications Summary

Procedure	Key Complications	Nursing Action
Carotid stenting	Stroke, TIA, hyperperfusion, bradycardia	Hourly neuro obs; BP 120–160 mmHg; atropine available
TIPS	Hepatic encephalopathy, haemoperitoneum	GCS/orientation hourly; ammonia; LFTs
UFE	Post-embolisation syndrome, pain, infection	Analgesia; temperature; vaginal discharge documentation
CDT thrombolysis	Major haemorrhage (ICH, GI, access)	Hourly bleed/neuro obs; fibrinogen 4–6h; stop if <100 mg/dL
Nephrostomy	Post-obstructive diuresis, sepsis, haematuria	Hourly UO; fluid replacement 50%; temperature; tube security
Lung biopsy	Pneumothorax, haemoptysis	CXR 1h and 4h; SpO₂; haemoptysis chart
Vertebroplasty	Cement leakage, neuro deficit	Lower limb neuro obs hourly x4h
PTBD	Cholangitis, haemobilia, bile leak	Temperature q4h; bile output; Charcot's/Reynolds vigilance

VTE Prophylaxis

VTE Prevention Post-IR Procedure

Risk stratify using Caprini or Padua score
Mechanical: TED stockings + SCDs for all immobile patients
Pharmacological: Resume anticoagulation when haemostasis confirmed (4–12h post arterial; 24–48h post high-bleed risk)
Early ambulation as tolerated; patient education on leg exercises and calf pain reporting
UFE and oncology patients: high VTE risk — early LMWH post-haemostasis