Pacer insertion – center over sublcavian vein of affected side. In other words, if the doctor is working on the patient's right side, then he's going to be inserting a guidewire into the right subclavian and sending toward the SVC. What you don't want him to do is feed that guidewire in a long way and just hang out with your c-arm centered at the right ventricle. That guidewire can sometimes turn and go up the neck. You are controlling his eyes (the c-arm) for this part of the procedure. As we know, we don't want to push a guidewire into a small vessel because you run a risk of dissection if pushed hard enough. At the very least, it will give the doc something to get upset at you about. Try to find out which lead is being placed first (atrial or ventricular), and once the guidewire is in the SVC, keep the atrium or ventricle in center of field, including as much wire as possible.
Spine – center to the level of surgical procedure. If you are doing a cervical spine, try to include C1 or C2 as a point of reference for the surgeon. It's not that he can't tell what vertebral level he's at, but any confirmation that he is in the correct location with his instruments will be reassuring. He's probably under a bit of stress... If you're doing a lumbar spine, you may want to consider placing T-12 at the top of your field so he can see ribs and count from there. For the T-spine, doing this would be out of your field of view. Depending on the doctor, they might have you count at the beginning of the procedure while he marks the correct location with a sharpie or needle.
Hip – acetabulum should be in the center of the field in the AP projection. It should be in the lateral margin of the field of view for the lateral projection. This would be an excellent procedure to use a manual technique on depending on your patient and the type of procedure being performed. I'll write more on manual techniques in a post in the near future.
Angiogram – center at occluded area. If you've never seen an angiogram or don't think you can spot an occlusion, just look for the pinched area of the vessel. If you're c-arm is equipped with digital subtraction, you could be asked to perform a runoff. This is when you will be following a bolus injection down an extremity (we'll say leg for example. You should try to do a practice run with fluoro before any contrast is injected. You will need to make sure that your c-arm is positioned so that you can simply roll it sideways down the extremity. As you are rolling, it might be a good idea to unlock the lock that allows you to move the image intensifier away from you to allow for slight bends and curves in the vessels. Just remember to try to keep all vessels in the center. You want to visualize them full of contrast, so if they're not dilated and crisp, you might want to slow your c-arm motion down until they are, then procede moving it distally once you have good fill.
ERCP – endoscope should be placed at 6 o’clock in the field of view. If you can remember the anatomy, the common bile duct (CBD) is the most inferior portion of what we would like to image. If we follow that duct superiorly, we will have a branch of the cystic duct (CD) leading to the gallbladder (GB). Once that branches off, it's no longer the CBD, but is not wht common hepatic duct (CHD). This branches into right and left hepatic ducts (RHD, LHD), and then into smaller vasculature that you may never need to name. Sometimes we'll even see the pancreatic duct (PD) cutting transversely away from the GB. When and injection is being made, get as much of the biliary tree as possible without clipping the CBD.
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