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Musculoskeletal Radiology Procedures Medication Orders – Adult/Pediatric – Inpatient/Ambulatory [117]

Musculoskeletal Radiology Procedures Medication Orders – Adult/Pediatric – Inpatient/Ambulatory [117] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number: 117

Delegation Protocol Title:
Musculoskeletal Radiology Procedures Medication Orders – Adult/Pediatric – Inpatient/Ambulatory

Delegation Protocol Applies To:
All UW Health inpatient and all UW Health ambulatory patients undergoing musculoskeletal radiology
procedures.

Target Patient Population:
Adult and pediatric patients undergoing musculoskeletal radiology procedures.

Delegation Protocol Champions:
Humberto Rosas, MD – Department of Radiology
Bradley Maxfield, MD – Department of Radiology

Delegation Protocol Reviewers:
Gina Greenwood, MBA– Director, Department of Radiology
Cindy Gaston, PharmD – Drug Policy Program
Jamie Nodolf, R.T.(R) – Manager, Interventional Radiology

Responsible Department:
Department of Radiology

Purpose Statement:
To delegate authority from the attending Radiologist to the Registered Radiologic Technologist (R.T.(R))
and Registered Diagnostic Medical Sonographer (RDMS) to place orders for medications used in the
course of performing Musculoskeletal Radiology procedures.

Who May Carry Out This Delegation Protocol:
Registered Radiologic Technologists (R.T.(R)s) and Registered Diagnostic Medical Sonographers (RDMS)
trained in the use of this delegation protocol.

The preparation of medications is within the scope of practice of Registered Radiologic Technologists
(R.T.(R)) and Registered Diagnostic Medical Sonographers (RDMS). Training on medication preparation
is included in the curriculum of their professional education programs, and is confirmed through their
licensure examination. Competence is further verified by the Department of Radiology as part of
routine staff development.

Guidelines for Implementation:
1. This protocol is implemented when a patient has an order for one of the Musculoskeletal Radiology
procedures listed in Table 1.
2. The delegate will review the patient’s medical chart for allergies to any medication in this protocol
and if they exist will consult the Radiologist to order an alternative agent.
3. When necessary, as indicated in the medication tables, the Radiologist communicates a preference
for dexamethasone or triamcinolone to the delegate through the electronic medical record.
4. The delegate will order dexamethasone instead of triamcinolone acetonide (Kenalog) if superficial
injection to minimize atrophy and skin pigmentation as determined by the Radiologist.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


5. The delegate references Table 1 to identify necessary medications for the specific procedure and
places orders for medications using order set: IP/OP – Musculoskeletal – Procedure –
Adult/Pediatric [5739]. Final volume of injection is determined by Radiologist performing the
procedure.
Order Mode:
Protocol/Policy, Without Cosign

References:
1. American Society of Radiologic Technologists. The Practice standards for medical imaging and
radiation therapy. Radiography Practice Standards. 2007.
2. American Society of Radiologic Technologists. The Practice standards for medical imaging and
radiation therapy. Sonography Practice Standards. 2015.
3. MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable corticosteroid and local anesthetic preparations:
a review for radiologists. Radiology 2009;252:647-61.
4. Robinson P , Keenan AM , Conaghan PG. Clinical effectiveness and dose response of image-guided
intra-articular corticosteroid injection for hip osteoarthritis. Rheumatology (Oxford) 2007; 46: 285–
291.
5. Louis LJ. Musculoskeletal ultrasound intervention: principles and advances. Radiol Clin North Am
2008; 46: 515– 533, vi.
6. Hollander JL. Intra-articular corticosteroid therapy. Am Pract Dig Treat 1961; 12: 190– 193
7. Blankenbaker DG, De Smet AA , Stanczak JD , Fine JP. Lumbar radiculopathy: treatment with
selective lumbar nerve blocks—comparison of effectiveness of triamcinolone and betamethasone
injectable suspensions. Radiology 2005; 237: 738– 741
8. Derby R, Lee SH , Date ES , Lee JH , Lee CH. Size and aggregation of corticosteroids used for epidural
injections. Pain Med 2008; 9: 227– 234.
9. Friedman DM, Moore ME. The efficacy of intraarticular steroids in osteoarthritis: a double-blind
study. J Rheumatol 1980; 7: 850– 856.
10. Rathmell JP , Aprill C , Bogduk N. Cervical transforaminal injection of steroids. Anesthesiology 2004;
100: 1595– 1600
11. Dreyfuss P, Baker R , Bogduk N. Comparative effectiveness of cervical transforaminal injections with
particulate and nonparticulate corticosteroid preparations for cervical radicular pain. Pain Med
2006; 7: 237– 242.
12. Ruetsch YA, Boni T , Borgeat A. From cocaine to ropivacaine: the history of local anesthetic drugs.
Curr Top Med Chem 2001; 1: 175– 182.
13. Benzon HT. Epidural steroid injections for low back pain and lumbosacral radiculopathy. Pain 1986;
24: 277– 295.
14. Scott DB. “Maximum recommended doses” of local anaesthetic drugs. Br J Anaesth 1989; 63: 373–
374.
15. Leone S , Di Cianni S , Casati A , Fanelli G. Pharmacology, toxicology, and clinical use of new long
acting local anesthetics, ropivacaine and levobupivacaine. Acta Biomed 2008; 79: 92– 105.
16. Cederholm I, Akerman B , Evers H. Local analgesic and vascular effects of intradermal ropivacaine
and bupivacaine in various concentrations with and without addition of adrenaline in man. Acta
Anaesthesiol Scand 1994; 38: 322– 327.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


Collateral Documents/Tools:
1. IP/OP – Musculoskeletal – Procedure – Adult/Pediatric [5739]
Approved By:
UW Health Ambulatory Protocol Committee: July 2015, *September 2015
UWHC Pharmacy and Therapeutics Committee: July 2015, *September 2015
UWHC Medical Board: August 2015, *October 2015
UW Health Chief Medical Officer: August 2015, *October 2015

Effective Date: October 2015

Scheduled for Review: October 2017
*addition of delegate: Sonographers and medication tables for Vertebroplasty and Biopsies.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


Extremity Injections

Ropivacaine
HCL 0.5%
(Naropin)
5mg/mL
Lidocaine HCL
1% Preservative
Free 10mg/mL
Bupivacaine
0.25%
2.5 mg/mL
Omnipaque
(Iohexol)
300 mg/mL
Dexamethasone
Sodium Phosphate
10 mg/mL
Triamcinolone Acetonide
(Kenalog)
40mg/mL
Volume
Injected
Iliopsoas Bursa 2 mL 2 mL ---- ---- ---- 1 mL (40 mg) 5 mL
Greater Trochanteric
Bursa
2 mL ---- ---- ---- ---- 1 mL (40 mg) 3 mL
Subacromial Bursa 1 mL 1 mL ---- ---- ---- 1 mL (40 mg) 3 mL
Piriformis 2 mL ---- ---- ---- ---- 1 mL (40 mg) 3 mL
Hamstring Tendon 4 mL ---- ---- ---- ---- 1 mL (40 mg) 5 mL
Biceps Tendon sheath
(US guided tenograms as well)
1 mL ---- ---- ----
†May use instead
of triamcinolone
1 mL (40 mg) 2 mL
Knee Joint 4 mL 4 mL ** ----
*
---- 1 mL (40 mg) 9 mL
Large Joint Injection:
(Hip & Shoulder)
2 mL 2 mL ** ----
*
---- 1 mL (40 mg) 5 mL
Medium Joint Injection
(Wrist, Elbow, & Ankle)
2 mL 2 mL ** ----
*
---- 1 mL (40 mg)

2.5 mL

Small Joint Injection
(Acromioclavicular, Hand,
& Foot )
1 mL 1 mL ** ----
*
1 mL (10mg)
†May use instead of
dexamethasone if deep structure
1-2 mL
Ganglion Cyst &
Morton’s Neuroma
---- 1 mL ---- ---- ---- 1 mL (40mg) 1 mL
Morton’s Neuroma
Ablation
---- ---- 0.4 mL ---- ---- 0.1 mL 100% EtOH 0.5 mL
Ischiofemoral Space 1 mL 1 mL ---- ---- ---- 1 mL (40mg) 3 mL
Tenogram ---- 7 mL ---- 3 mL 1 mL (10mg) ---- 11 mL
NOTE: 1% Lidocaine (Xylocaine) 10mg/mL and 8.4% Sodium Bicarbonate (9mL/1mL) are used for local anesthesia of the subcutaneous tissues on
every procedure.
NOTE: When using Lidocaine, always use the preservative-free (P-F) version if you are going to mix it with corticosteroids or if you are administering
deep anesthesia through a needle you will use to aspirate for infection. This will be determined by the physician performing the procedure.
* For fluoroscopically guided injections, particularly joint injections, contrast is needed to confirm needle placement. If allergic to nonionic contrast
agents such as Iohexol, use Gadoterate Meglumine (Dotarem) 0.5 mmol per mL or air.
** If corticosteroids are not being used and only anesthetic is being requested, switch to 2% Lidocaine HCl 20mg/mL (5mL vial)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org




† Use Dexamethasone instead of Triamcinolone Acetonide (Kenalog) if superficial injection to minimize atrophy and skin pigmentation as determined by
the physician.

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org




Arthrogram Injections

Lidocaine HCL 1%
Preservative Free
10mg/mL
Omnipaque
(Iohexol)
300 mg/mL
Ropivacaine HCL 0.5%
(Naropin) 5mg/mL
0.9 % NaCL
Preservative Free†
Dotarem
(Gadoterate Meglumine)
0.5 mmol per mL
Volume
Injected
MR Arthrogram
Hip 5 mL 5 mL 5 mL 5 mL 0.1 mL 12-15 mL
Knee 20 mL 10 mL 10 mL 0.2 mL 40 mL
Shoulder 10 mL 5 mL 5 mL 0.1 mL 12-15 mL
Elbow 10 mL 5 mL 5 mL 0.1 mL 3-6 mL
Radiocarpal 10 mL 5 mL 5 mL 0.1 mL 2-4 mL
CT Arthrogram
Hip 5 mL 10 mL 5 mL 12-15 mL
Knee 20 mL 20 mL 40 mL
Ankle 5 mL 5 mL 5-10 mL
Shoulder 10 mL 10 mL 12-15 mL
Elbow 5 mL 5 mL 3-6 mL
Radiocarpal 5 mL 5 mL 2-4 mL
Aspirations

Lidocaine HCL 1%
Preservative Free
10mg/mL
Omnipaque (Iohexol)
300 mg/mL
Sterile Water
Fluoroscopy 10 mL 5 mL 10 mL
Ultrasound 10 mL 10 mL
NOTE: 1% Lidocaine (Xylocaine) 10mg/mL and 8.4% sodium bicarbonate (9mL/1mL) are used for all procedures for local
anesthesia of the subcutaneous tissues.
NOTE: For LIDOCAINE ALLERGIC PATIENTS:
Use chloroprocaine (Nesacaine) )\ 1% for skin. Since chloroprocaine has methylparaben in it, you shouldn’t mix it with triamcinolone
(Kenalog) or dexamethasone. An order must be placed in advance of the procedure by the physician.
Use tetracaine (Pontocaine) () with the steroid. It comes as a powder which needs to be mixed with sterile water. Use the same quantities as
you would for ropivacaine. An order must be placed in advance of the procedure by the physician.
† 0.9% Bacteriostatic NaCl may also be used based on availability.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org





Arthrogram Injections

Lidocaine HCL 1%
Preservative Free
10mg/mL
Omnipaque
(Iohexol)
300 mg/mL
Ropivacaine HCL 0.5%
(Naropin) 5mg/mL
0.9 % NaCL
Preservative Free†
Dotarem
(Gadoterate Meglumine)
0.5 mmol per mL
Volume
Injected
MR Arthrogram
Hip 5 mL 5 mL 5 mL 5 mL 0.1 mL 12-15 mL
Knee 20 mL 10 mL 10 mL 0.2 mL 40 mL
Shoulder 10 mL 5 mL 5 mL 0.1 mL 12-15 mL
Elbow 10 mL 5 mL 5 mL 0.1 mL 3-6 mL
Radiocarpal 10 mL 5 mL 5 mL 0.1 mL 2-4 mL
CT Arthrogram
Hip 5 mL 10 mL 5 mL 12-15 mL
Knee 20 mL 20 mL 40 mL
Ankle 5 mL 5 mL 5-10 mL
Shoulder 10 mL 10 mL 12-15 mL
Elbow 5 mL 5 mL 3-6 mL
Radiocarpal 5 mL 5 mL 2-4 mL
Aspirations

Lidocaine HCL 1%
Preservative Free
10mg/mL
Omnipaque (Iohexol)
300 mg/mL
Sterile Water
Fluoroscopy 10 mL 5 mL 10 mL
Ultrasound 10 mL 10 mL
NOTE: 1% Lidocaine (Xylocaine) 10mg/mL and 8.4% sodium bicarbonate (9mL/1mL) are used for all procedures for local
anesthesia of the subcutaneous tissues.
NOTE: For LIDOCAINE ALLERGIC PATIENTS:
Use chloroprocaine (Nesacaine) )\ 1% for skin. Since chloroprocaine has methylparaben in it, you shouldn’t mix it with triamcinolone
(Kenalog) or dexamethasone. An order must be placed in advance of the procedure by the physician.
Use tetracaine (Pontocaine) () with the steroid. It comes as a powder which needs to be mixed with sterile water. Use the same quantities as
you would for ropivacaine. An order must be placed in advance of the procedure by the physician.
† 0.9% Bacteriostatic NaCl may also be used based on availability.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org




Peripheral Nerve Blocks

Lidocaine HCL 1% Preservative Free
10mg/mL
Dexamethasone Sodium Phosphate
10 mg/mL
Bupivacaine 0.25%
2.5mg/mL
Volume to inject
Ganglion
Stellate Ganglion 1ml Test Injection 1ml (10mg) 5 mL 7 mL
Ganglion Impar 1ml (10mg) 4 ml 5 ml
Medium Size Nerve
Ulnar Nerve 3 mL 1 mL (10 mg) 4 mL
Tibial Nerve 3 mL 1 mL (10 mg) 4 mL
Obturator Nerve 3 mL 1 mL (10 mg) 4 mL
Saphenous Nerve 3 mL 1 mL (10 mg) 4 mL
Lateral Femoral
Cutaneous Nerve
3 mL 1 mL (10 mg) 4 mL
Small-Sized Nerve
Sural Nerve 1 mL 1 mL (10 mg) 2 mL
Pudendal Nerve 1 mL 1 mL (10 mg) 2 mL
Greater Occipital 1 mL 1 mL (10 mg) 2 mL
Digital Nerve 0.5 mL 0.5 mL (5 mg) 1 mL
NOTE: 1% Lidocaine (Xylocaine) 10mg/mL and 8.4% Sodium Bicarbonate (9mL/1mL) are used for all procedures for local anesthesia of the
subcutaneous tissues.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org





Vertebroplasty

Lidocaine HCL 1% Preservative Free
10mg/mL
Ropivacaine HCL 0.5% (Naropin) 5mg/mL Volume Injected
Fluoroscopy 10 mL 10 mL 5-20 mL
CT 10 mL 10 mL 5-20 mL
Biopsy (For Pathology*)

Lidocaine HCL 1% Preservative Free
10mg/mL
Ropivacaine HCL 0.5% (Naropin) 5mg/mL
Volume Injected
Fluoroscopy 10 mL 10 mL 5-20 mL
Ultrasound 10 mL 10 mL 5-20 mL
CT 10 mL 10 mL 5-20 mL
NOTE: 1% Lidocaine (Xylocaine) 10mg/mL and 8.4% sodium bicarbonate (9mL/1mL) are used for all procedures for local
anesthesia of the subcutaneous tissues.

* Biopsy may be of a bone lesion of soft tissue mass. If an aspiration is performed at the same time as the biopsy, please refer to the aspiration
chart for additional medications required for the procedure.

NOTE: For LIDOCAINE ALLERGIC PATIENTS:
Use chloroprocaine (Nesacaine) )\ 1% for skin. Since chloroprocaine has methylparaben in it, you shouldn’t mix it with triamcinolone
(Kenalog) or dexamethasone. An order must be placed in advance of the procedure by the physician.
Use tetracaine (Pontocaine) () with the steroid. It comes as a powder which needs to be mixed with sterile water. Use the same quantities as
you would for ropivacaine. An order must be placed in advance of the procedure by the physician.


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org