Chapter 101

• Availability of appropriately trained interventional radiologists is an important component of ICU patient care.
• Interventional radiologic techniques may be prophylactic (e.g., use of vena caval interruption to prevent pulmonary embolism), diagnostic (e.g., angiography in gastrointestinal hemorrhage), or therapeutic (e.g., drainage of abscess, control of gastrointestinal hemorrhage through embolotherapy or vasoconstrictor infusion, creation of transjugular intrahepatic portosystemic shunts [TIPS], or retrieval of a foreign body).
• Interventional radiologic techniques are as effective as many open surgical techniques but carry lower morbidity and mortality in the ICU patient.
• Interventional radiologic techniques should be considered in ICU patients when the risk of more invasive procedures is greater and the outcome is not predictably better.
• Appropriate ICU monitoring devices and support systems (oxygen, suction, ventilation, ICU-type personnel) must be available in the radiology suite for safe management of ICU patients.

Interventional radiology encompasses a wide variety of percutaneous procedures that use one or more imaging modalities to guide the placement of needles, guidewires, and catheters. The choice of fluoroscopy, ultrasound (US), and/or computed tomography (CT) depends on the patient, the clinical circumstances, and the procedure. Many of these procedures are performed as an alternative or adjunct to surgery because they are less invasive and carry a lower overall morbidity and mortality as compared with the comparable surgical intervention. This fact is particularly important in ICU patients, who frequently are poor surgical candidates and for whom procedures carry a higher-than-average risk owing to associated comorbidities. Furthermore, while many surgical procedures require general anesthesia or deep conscious sedation, interventional radiology procedures typically can be performed with mild to moderate levels of conscious sedation and/or local anesthesia, further reducing the risk, the length of the procedure, and the need to consult the anesthesiology service for assistance.

Deciding when and where to perform an interventional radiologic procedure is often a difficult decision requiring close communication and cooperation between the critical care and interventional staffs. The interventional radiologist should be consulted early to allow adequate time for a meaningful exchange between the two services.

In general, working with “stable” patients is preferable, although not always possible. In certain situations, it is better to proceed with an examination despite patient instability. For instance, in a patient with gastrointestinal (GI) bleeding, instability may indicate active bleeding, and immediate angiography during ongoing bleeding is necessary to identify the source. If the patient is stabilized first, the opportunity to locate the bleeding site may be lost. Nevertheless, despite the need for prompt treatment, the appropriate venous lines, oxygen support, monitoring devices, and fluid resuscitation and blood product administration should be initiated prior to any interventional procedure.

The risks in complex interventional procedures are minimized and the success enhanced when the patient is transported to the special procedures suite. Although CT and US are useful for some nonvascular procedures, fluoroscopic guidance is required for all vascular interventions and many nonvascular procedures. Portable fluoroscopy units are available in most ICUs, but ...

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