# Obtain the referring physician's name, phone number and beeper number.

# Obtain the name of the patient, the patient's phone number and their medical record number.

# Review the patient's medical history with the referring physician. We need to know if we are going to biopsy a primary lesion or a metastatic lesion. If the lesion is a primary, the case must be discussed with the orthopedic surgeon who will be doing the definitive resection so that we do not violate any potential skin flaps or neurovascular bundles that need to be preserved. If the lesion is a suspected metastasis, make sure we are planning to biopsy the most accessible lesion.

# Ask the doctor if there is a current INR and CBC in the chart. If not, we will need to obtain these before the biopsy. Make sure patient has adequate platelets and normal INR before we do a biopsy. We can not do a biopsy on a patient on anticoagulant drugs.  A History and Physical (H+P) must have been entered in the patient charts in the 30 days prior to the biopsy, or will need to be repeated by the fellow immediately prior to the biopsy.  Clearly the prior is the better option.

# Ask the doctor where the patient's imaging studies were obtained and their current location. Review the imaging studies before the patient comes and decide if the request is appropriate, what area to biopsy and what needles will be necessary. If you think the study is not indicated, please discuss the case with the attending radiologist before you refuse to do the procedure.

# Call Radiology Scheduling at 543-3405 (or Sheila 33372) to set up a time for the biopsy. The best time to do a biopsy is in the early part of the day (preferably between 10 am and 3 pm) because nursing staff is available at that time. There should be a faculty person on the schedule when a biopsy is being performed. In general, we do our invasive procedures under CT guidance. Usually we need about 90 minutes of CT or flouroscopy time for a biopsy.

# For outpatients, remind Scheduling to set up a preadmission at least one 1 hour prior to the procedure in SAMA as well as a 2 hour post-procedure recovery time in SAMA/PACU (36130). Remind scheduling to let the patient know that they will probably undergo conscious sedation and need to arrange for a ride home. They will not be allowed to drive home by themselves after sedation. All patients should be NPO for at least 4 hours prior to their biopsy.

# Minors must be accompanied by someone who can legally give consent.

# Fill out the preoperative order sheet for SAMA. Request an IV on all patients coming for a biopsy. If there is no current PT/PTT available,order a stat PT/PTT to be drawn in SAMA the morning of the admission.

# Scheduling will notify the radiology nurses about the procedure. Lydia, the head nurse in Angio/IR will pick up the preoperative order sheet and arrange for a nurse to be available to sedate and monitor the patient. If the procedure is being done on short notice, talk to Lydia (543-5215) in Angio/IR directly about the procedure to see if she can arrange for a nurse.

# Make sure the bone biopsy needles are autoclaved and avialable. The Manon needles are kept in Angio/IR. The Ackerman needles are kept in the central processing area. The Craig needles (rarely used) are kept in the OR and need to special requested the day before the biopsy. All the soft tissue cutting needles are available through Angio/IR.

# Notify Cytology/Pathology (543-5378) if you want someone on call to prepare and look at your specimen during the procedure. Do not call them unless you think it is necessary. If pathology is coming down, they will bring the formalin with them.

# Order the chart.   This can be done through Carol Guard.  Check needles in Bx box.  This is kept in Mini/Tudor's office on the top of the bookcase to the right of the door.

# Gather all the necessary supplies for the procedure! Assume there is nothing in the CT suite except sterile gloves and a garbage can.

# Check the H+P is current.

# Fill out and sign the short H&P form developed for outpatient invasive procedure. Be sure to ask about allergies and medications. Make sure women of child-bearing age are not pregnant. Give the patient the pink copy that includes a phone number for the patient to call if they are experiencing any difficulties after the procedure or give them a copy of the post-biopsy instructions for patients that are in the locker in the procedures binder.

# Obtain informed consent and have the patient sign the consent form. Patient's must be notified of the risk of bleeding, neurologic compromise, infection and death. If the patient is under 18 years of age, consent must be obtained from the parent or legal guardian.

# Have the patient void before starting the procedure.

# Prescan the area of the biopsy with an external grid to localize the lesion. Make sure the lesion is unequivocally visible prior to starting the biopsy. When you have selected an appropriate biopsy level, mark the area on the skin using a permanent ink marker. Measure the depth of the needle and the angle of the approach.

# Start patient sedation to minimize biopsy pain. I like to use small incremental doses of Versed prior to the biopsy and Fentanyl just before the biopsy because they work well and are easily reversible. Please refer to the handout on conscious sedation prepared by the UCSD Anesthesia/Pharmacy departments if you are not familiar with these drugs. The patient must be on an oximeter and be hemodynamically monitored throughout the procedure if sedation is used.

# Perform the biopsy observing universal precautions in all patients.

# Properly dispose of all biopsy equipment. Remember that the Ackerman and Craig needles are not disposable and need to be set aside to be autoclaved.

# Write a progress note for the patient's chart. The progress note must include the drugs that were administered during the procedure.

# Sign the sedation log that the nurse has filled out with the drugs used, doses and patient vital signs.

# Fill out orders for the recovery room in SAMA. Patients can eat as soon as they are alert and oriented. They should be monitored for hemodynamic decompensation and the biopsy site needs to be observed frequently for bleeding.

# Fill out the bone procedure log book.

# Check the patient in SAMA prior to discharging them. Make sure they have instructions not to drive home by themselves. The patient must have a phone number to contact in case they have any questions or problems. We usually give them the number of the radiology front desk (543-2280) and the beeper number of the bone fellow on call.

# Call the patient to see how they are doing. Document that you have called on post-surgery telephone follow-up form.

# Check on any preliminary results of the biopsy.