UCSD Musculoskeletal Radiology

bonepit.com

Contrast Media

Guidelines

 

   
   

 

UCSD HEALTHCARE

UCSDMC POLICY/PROCEDURE-RADIOLOGY

Intravenous Contrast Media Guidelines-Adult

 

                                                                                                            Revision Date: 12/04/06

Per John Hesselink, M.D.

 

 

Approval Signature:  ______________________

 

 

Title:  INTRAVENOUS CONTRAST MEDIA GUIDELINES-ADULT

 

 

Policy Statement

To establish guidelines for the prevention, diagnosis and treatment of contrast media reactions after intravascular injection, and to reduce the chance of inducing contrast media nephrotoxicity.

 

Responsible Party

All Radiologists, Radiology Residents and Fellows, Radiology

Technologists, Radiology Nurses, Student Technologists and Technical Assistants

 

 

PROCEDURE

 

I.  Intravenous Access

 

A.  When the power injector is utilized, a 22 gauge or larger needle/cannula 1.25Ē to 1.5Ē length is preferred for IV contrast injection.  It is advisable to obtain a good backflow of blood to test adequate positioning of the needle in the vein.  Adequate position of the cannula in the vein is checked again by flushing the IV with 10 ml of saline flush before injecting the contrast agent.

 

B. Use of existing access routes:

1.      Only power-injection rated PICC lines (purple) are approved for CT use.

2.      Pre-existing IV lines will be flushed with 10ml of saline flush to ensure patency prior to contrast injection.

3.      Port-a-cath to be accessed by Radiology R.N. or Radiologist, with training.  If no trained staff is available, send patient to the Infusion Center or Cancer Center.

4.      Consult Radiologist/ Radiology RN prior to using any central line catheters.

 

 

 

IIa.  Prevention of Nephrotoxicity with Iodinated Contrast Media

 

A.  Requirements for CREATININE testing prior to iodinated contrast media injections (for the purpose of reducing the chance of contrast-induced renal failure):

A.1.     Patients > 50 years of age are to have a recent (within 30 days) serum creatinine prior to contrast injection.

B.2.     Patients < 50 years of age do not require labs, UNLESS the patient has one or more of the following:

     An underlying medical condition that impairs the renal system

     Cancer

     Recently (within 30 days) had chemotherapy

     History of renal disease.

     Diabetes mellitus

     Receiving treatment with potentially nephrotoxic drugs

3.   When clinical findings or history raise doubt about the patientís current renal function, a STAT creatinine should be done prior to injecting contrast media.

 

B. If the serum creatinine is > 1.5 mg/dl, the referring clinician should be called and advised about alternative imaging approaches, such as MRI or a non-contrast CT.  If the creatinine is > 1.5 but < 2.0 mg/dl, and the referring physician and radiologist have determined that a contrast-enhanced imaging study must be done to obtain critical medical information, the contrast may be given with the following precautions:

1.  Patient should be pretreated with Mucomyst (N-acetylcysteine), either:

a.  Orally, 600 mg twice daily on the day before and the day of the contrast imaging study, or

b.  Intravenously, 150 mg/kg over 30 minutes before contrast administration, followed by 50 mg/kg over 4 hours.

2.  Bicarbonate 150 mEq in 1000 cc D5W, 3 cc/kg bolus, then 1 cc/kg/hr x 6 hours.

3.  Adequate patient hydration must be maintained (See Section E).

 

C.  Adequate patient hydration is important to minimize the risk of nephrotoxicity.  Unless monitored by anesthesia, no patient receiving radiographic contrast should have NPO orders.  If the patient cannot take adequate oral fluids, consider intravenous infusion of 0.45% sodium chloride at 100 ml/hr, beginning 6-12 hours before and 4-12 hours after the administration of contrast material. 

 

D. All patients should be encouraged to drink lots of fluids for several hours after receiving contrast material.

 

E.  For patients with end-stage renal disease who are on chronic renal dialysis, noncontrast or non-iodinated, contrast-enhanced imaging should be considered.  If iodinated agents are used, the imaging study should be scheduled before the patientís dialysis on the same day, or dialysis can be done within 24 hours after contrast injection.

 

 

 

 

IIb.  Prevention of Nephrotoxicity with Gd-based Contrast Agents for MRI

 

Gadolinium-based contrast agents using a standard dose (0.2 ml/kg [0.01 mmol/kg]) are very safe in patients with normal renal function.  However, Gd-based contrast agents have been implicated in causing Nephrogenic Systemic Fibrosis (NSF).  Reported cases were patients with severe renal dysfunction (on dialysis or GFR < 15 ml/min), and most patients received double or triple doses of gadodiamide (Omniscan, Amersham/GE). Therefore, we have set the following guidelines for giving Gd-based contrast agents for MRI:

 

A.  Patients with no known renal dysfunction do not need to be screened for serum creatinine levels.

 

B.  For patients with severe renal dysfunction (on dialysis or GFR < 15 ml/min) who are scheduled for a Gd-enhanced MRI, the indications for the study should be assessed.  If gadolinium is not necessary, a non-contrast MRI should be performed, and the referring physician should be informed about the change in the ordered exam.  If gadolinium might be helpful, the referring physician should be called to discuss the risks and benefits of giving gadolinium to the patient.  If the clinician decides to proceed with a gadolinium-enhanced study, the risks and benefits should be discussed with the patient, and he/she can decide whether or not to have the contrast.  If the patient wants to receive the Gd-based contrast agent, then:

1.   Have patient sign our special consent form that addresses the risks

2.   Do not use Omniscan

3.   Dose at no more than 0.2 ml/kg (0.01 mmol/kg)

4.   Require same-day dialysis after the scan

 

C. Any patients receiving more than 20 ml (double or triple dose) of Gd-based contrast agent should be screened with serum creatinine.  If the serum creatinine is > 1.5, no more than 20 ml should be given.

 

 

III.  Prevention of Allergic-Type Contrast Reactions

 

A.     For patients receiving iodinated contrast media, obtain a complete history of allergies to medications and food, as well as previous reactions.

1.      The patient is to fill in the attached questionnaire (Patient Questionnaire- Intravenous/Intra-arterial Contrast D322).

2.      The technologist is to review the questionnaire with the patient prior to injection.

3.      The questionnaire is part of the patientís medical record.  The Technologist is to complete the information regarding type and volume of contrast and reactions, then sign questionnaire, post injection

4.      Non-Ionic contrast media is the preferred contrast for intravenous contrast injection. 

For patients receiving gadolinium contrast media, ask about any prior reactions to dyes or contrast used in X-ray, CT, or MRI.

 

B.     For patients receiving iodinated contrast media, pre-treatment to prevent or lessen reactions should be given under the following guidelines:

1.      Patients with history of

        Prior mild contrast reaction

        Moderate or severe reaction to foods or medications.  Moderate or severe reactions include any reaction more severe than itching and/or hives.

        Asthmatics, actively using inhalers or medications

Note:  if an asthmatic patient is under the care of a pulmonary physician, check with their physician prior to prescribing steroids.

2.      If a patient arrives without being pre-treated, it is preferable to reschedule the exam to allow steroid treatment.  Alternative options are at the discretion of the Radiologist.   If there is a history of moderate to severe contrast reaction, another radiological procedure (MRI, non-contrast CT, US or Nuclear Medicine) should be considered as an alternative.

 

In an emergency situation (e.g. r/o pulmonary emboli), oral Prednisone can be substituted with Hydrocortisone 200 mg, IV, given 6 hrs and 2 hrs before the contrast injection.  Benadryl, 50 mg p.o., should still be given 1 hr before the injection.

 

For patients receiving gadolinium contrast media who have had a prior severe reaction to iodinated contrast or moderate or severe reaction to gadolinium contrast media, the referring physician should be called to discuss the following 2 options:

1.   Perform a non-contrast MRI only, or

2.   Pre-treat according to the protocol below before giving the gadolinium contrast agent.

 

Medication

Type

Dose

Dose Time

Prednisone

Steroid

50 mg p.o.

 13 hrs, 7 hrs, and 1 hr prior to injection

Benadryl

Antihistamine

50 mg p.o.

1 hr prior to injection

 

C.  Do not remove the I.V. line from the patient until the exam is completed and it is confirmed that the patient is not experiencing any reaction to the contrast injection.  If there is an extravasation, refer to the Extravasation Policy.

 

D.    The emergency equipment will be checked daily.

 

E.     Documentation:  All injections will be documented in the Radiology Information System (patient notes) and written on the bottom portion of the IV contrast questionnaire and/or in the patient progress notes.  The questionnaire and if used, the progress notes are to be included in the patientís Medical Records. The documentation must include:

1.      Date and Time of injection                                  4.  Volume injected

2.      Contrast type utilized                                            5.  Any reactions

5.3.              Pre-treatment if given                                               6.  Any Treatments

 

Any adverse reactions to contrast (including hives) must be documented in the (RIS) Radiology Information System (Patient Notes), on an eQVR, and in the dictation of the exam/procedure.

 

 

 

 

IV.  Diagnosis of Contrast Reactions

 

Look for any signs of contrast reaction, no matter how mild they may seem.

 

Severity of Reaction

Symptoms

Treatment

Mild

Nausea, warmth (heat), pallor, flushing

(these are normal physiological responses to contrast injection and do not require intervention or documentation)

 

Cough, headache, dizziness, vomiting, anxiety, altered taste, itching, , chills, shaking, sweats, rash (hives),

Signs and symptoms appear self-limited without evidence of progression (e.g. limited urticaria with mild pruritis, transient nausea, and one episode of emesis).  Requires observation (15 Ė20 minutes) to confirm resolution and/or lack of progression but usually no treatment.  Patient reassurance is usually helpful.

Moderate

(moderate degree of clinically evident focal and/or systemic signs/symptoms)

nasal stuffiness, swelling-eyes or face,  tachycardia/ bradycardia, hypertension, bronchospasm (wheezing), dyspnea, laryngeal edema, pronounced cutaneuous reaction

The symptoms listed are considered as indication(s) for immediate monitoring and treatment.  These situations require close, careful observation for possible progression to a life-threatening event.

Severe

(Life-threatening with more severe signs/symptoms)

Laryngeal edema, profound hypotension, unresponsiveness, convulsions, clinically manifested arrhythmias, cardiopulmonary arrest

Requires immediate recognition, monitoring and treatment, almost always requires hospitalization

 

*Dial 6111 for Code Blue

 

THE MOST IMPORTANT ISSUE IS TO RECOGNIZE THAT A CONTRAST REACTION HAS OCCURRED, TO ASSESS THE SEVERITY OF THE REACTION, AND TO EVALUATE THE NEED FOR VIGOROUS RESUSCITATION (CODE BLUE)

 

V.  Management of Contrast Reactions

 

A.     Patients experiencing reaction will be monitored according to the severity of the reaction.

1.      If there are few hives only, the patient may be discharged from the department as soon as the hives begin to fade, and the patient is medically stable.

2.      If the reaction is more severe follow the treatment on the following pages.

 

B.     Treatment of Acute Reactions:

 

Reaction

Treatment (specific)

Comments

Hives / Urticaria

        Discontinue injection, if not completed

        No treatment needed in most cases

4.Give antihistamine Benadryl 25-50 mg (PO, IM or IV)

If severe/widely disseminated:

Alpha-agonist (arteriolar and venous constriction):

     Epinephrine SC or IM

(1:1,000) 0.1-0.3 ml (if no cardiac contraindication)

Facial/Laryngeal Edema

        Give Alpha-agonist (arteriolar and venous constriction): Epinephrine SC (1:1,000) 0.1-0.3 ml or if hypotension evident, then give epinephrine (1:10,000) slowly IV 1.0 ml, repeat

        O2  6-10 L/Min (via mask)

If not responsive to therapy or for obvious laryngeal edema (acute), seek appropriate assistance (code blue)

Consider intubation

Bronchospasm

        O2 6-10 L/min via mask

        Monitor:  ECG; O2 saturation (pulse oximeter); BP

        Give Beta agonist inhalers:  Alupent, Brethaire, Albuterol

Epinephrine SC or IM (1:1,000) 0.1-0.3 ml, if hypotensive give (1:10,000) slowly IV 1.0 ml. Repeat prn up to a max. 1.0 mg

Alternatively:

1.      Aminophylline:

6.0 mg/kg IV in D5W over 10-20 min (loading dose); then 0.4-1.0 mg/kg/hr, prn

2.  Call for assistance (CODE) for severe bronchospasm or if 02 sats < 88 persists

Hypotension with Tachycardia

        Legs up 60 degrees or more (preferred) or Trendelenberg position

        Monitor:  ECG, pulse ox, BP

        Give O2 6-10 L/min (via mask)

        Rapid administration of large volumes of isotonic Ringerís Lactate or Normal Saline.

If poorly responsive:

Epinephrine (1:10,000) slowly IV, 1 ml (0.1 mg) (if no cardiac contraindications). Repeat as needed up to a maximum of 1 mg. Call Code Blue and/or transfer to Emergency Department for further care.

Hypotension with Bradycardia-Vagal Reaction

        Monitor vital signs

        Legs up 60 degrees or more (preferred) or Trendelenberg position

        Secure airway; give O2 6-10 L/min(via mask)

        Secure IV access; push fluid replacement with Ringerís Lactate or NS

        Give atropine 0.6Ė1 mg IV slowly if patient does not respond quickly to above.

        Repeat atropine up to a total dose of 0.04 mg/kg (2-3 mg) in adults.

Call Code Blue and/or transfer to Emergency Department for further care.

Hypertension,

Severe

        Give O2 6-10 L/min (via mask).

        Monitors in place, ECG, pulse ox., BP

        Give nitroglycerin 0.4 mg tablet, sublingual (may repeat x3); topical 2% ointment, apply one inch strip

        Sodium nitroprusside arterial line: infusion pump necessary to titrate

        Transfer to ICU or emergency department

        For pheochromocytoma-phentolamine

      5.0 mg (1.0mg in children) IV

 

Seizures/

Convulsions

        Give O2 6-10 L/min via mask

        Consider diazepam (Valium) 5.0 mg or midazolam (Versed) 2.5 mg IV

        If longer effect needed, obtain consultation; consider phenytoin (Dilantin) infusion 15-18 mg/kg at 50 mg/min

        Careful monitoring of vital signs required

        Consider CODE for intubation if needed.

Call Code Blue and/or transfer to Emergency Department for further care.

Pulmonary Edema

        Elevate torso; rotating tourniquet (venous compression)

        Give O2 6-10 L/min via mask

        Give diuretics-furosemide (Lasix) 20-40 mg IV slow, push

        Consider Morphine (1-3 mg IV)

        Corticosteroids optional

Call Code Blue and/or transfer to Emergency Department for further care.

 

V.VI.  Documentation

 

A.     For mild, requiring medical intervention, to severe contrast reactions:

        Radiologist will document the reaction on a Progress Note for the patientís medical record and include it in the dictated report.

        Technologist will document the reaction in the RIS (Patient Notes) and complete an eQVR.

 

B.     Patient Questionnaire Form (D322) insertion into the patientís Medical Records Chart after all information is documented.

1.      Inpatients: Upon completion of the procedure/exam the completed Patient Questionnaire Form will be placed in the designated location for progress notes.

2.      Outpatients:  Upon completion of the procedure/exam, the completed Patient Questionnaire Form will be placed in the front of the Outpatientís Medical Record Chart.  If the outpatient Medical Record chart is not available, send the completed Questionnaire Form to the Medical Records Department.

 

C.    Dictated Reports:  The Radiologist must include:

1.      Date and Time of injection                                 4.  Volume injected

2.2.  Contrast type utilized                                        5.  Any reactions

5.3.  Pre-treatment if given                                       6.  Any Treatments

 

 

 

References:  American College of Radiology - Manual on Contrast Media