Duke Radiology Contrast Media Guidelines Final 10.13.16 PDF
Duke Radiology Contrast Media Guidelines Final 10.13.16 PDF
Duke Radiology Contrast Media Guidelines Final 10.13.16 PDF
October 2016
Table of Contents
5. Metformin Guidelines………………………………………………………………………page 11
12. References……………………………………………………………………………………...page 23
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I. Introduction
Contrast media is used to improve medical imaging. Various forms of contrast media
can be administered intravenously, intra-arterially, or intraluminally. Contrast media is
considered a pharmaceutical agent and like all other pharmaceuticals, contrast media is not
completely devoid of risk. The purpose of these guidelines is to assist the radiologist in
managing the small but real risks inherent in the use of contrast media.
Before any administration of contrast media, the radiologist should consider the following:
The following parameters will be used when assessing patients requiring IV iodinated
contrast media:
1. All patients with a serum creatinine (regardless of age) which measures <
2.0 mg/dL (and/or eGFR > 40) are eligible for intravenous iodinated
contrast administration.
2. All patients >60 years old require a serum creatinine (and/or eGFR)
performed within the last 30 days.
3. Patients < 60 years old, scheduled for a routine intravascular study, and do
not have one or more risk factors (listed below), do not require a baseline
serum creatinine (and/or eGFR) determination before iodinated contrast
medium administration.
4. Administration of intravenous contrast with serum creatinine ≥ 2.0 mg/dL
(and/or eGFR ≤ 40) requires discussion with radiologist. The radiologist
should consider discussing the risks of contrast-induced nephropathy (see
page 12) with a member of the patients care team which may include the
requesting physician or physician extender prior to approval of contrast
administration.
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3. Renal disease: Patients with a history of significant renal disease (e.g. may
result in impaired renal function), nephrectomy, kidney transplant, or
recognized upward trend in creatinine may have a point of
care creatinine performed at the discretion of the nurse, technologist,
radiologist, or ordering provider.
4. Hypertension requiring medical therapy, diabetes mellitus, or gout:
patients with one or more of these three conditions may have a point of care
creatinine performed at the discretion of the nurse, technologist, radiologist,
or ordering provider.
5. Recent intravenous contrast: All patients who have received IV iodinated
contrast in the last 24 hours require approval by a radiologist for
additional intravenous contrast media administration and may have a
point of care creatinine performed at the discretion of the nurse,
technologist, radiologist, or ordering provider.
Emergency patients
The ordering physician can choose to bypass screening in an emergency and have IV
contrast administered without screening. This screening process bypass must be
documented by the nurse, technologist or the ordering physician. The ordering physician’s
name must be included in the documentation.
IV. Gadolinium
Eligibility criteria for administration of intravenous gadolinium are described in the section
on Gadolinium guidelines (see page 13).
V. Specific conditions
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6. Thyroid Disease:
a. Hyperthyroidism: patients with hyperthyroidism or other thyroid disease
can potentially experience iodine-provoked delayed hyperthyroidism. This
effect may appear 4-6 weeks after IV administration of iodinated contrast
media. This condition is usually self-limited. However, patients with history
of hyperthyroidism should follow-up with their endocrinologists after
receiving iodinated contrast media (1, 4).
b. Thyroid carcinoma: Iodinated contrast media may interfere with both
diagnostic scintigraphy and radio-iodine treatment. Therapeutic uptake of
I131 radioiodine therapy may be decreased substantially after iodinated
contrast injection. Patients are required to wait a minimum of 4 weeks
(preferably 6 weeks) after receiving intravenous iodinated contrast
administration, before undergoing either I123 diagnostic scintigraphy or I131
radioiodine therapy (1, 4).
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I. Allergic-like reactions to contrast media
1. Mild:
Allergic-like: limited urticarial/pruritus, cutaneous edema, “itchy”/
“scratchy” throat, nasal congestion, sneezing, rhinorrhea
Physiologic: limited nausea/vomiting, transient flushing, headache,
dizziness, mild hypertension, vasovagal reaction that resolves spontaneously
2. Moderate:
Allergic-like: diffuse urticarial/pruritus; diffuse erythema (stable vital signs),
facial edema or throat hoarseness without dyspnea, wheezing with no
hypoxia
Physiologic: protracted nausea/vomiting, isolated chest pain, vasovagal
reaction requiring treatment
3. Severe:
Allergic-like: diffuse or facial edema with dyspnea, diffuse erythema with
hypotension, laryngeal edema with stridor and/or hypoxia,
wheezing/bronchospasm with hypoxia, anaphylactic shock (hypotension +
tachycardia)
Physiologic: vasovagal resistant to treatment, arrhythmia, seizures,
hypertensive emergency, cardiovascular collapse
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I. Premedication guidelines
1. Steroid prep needed (if no prep given, consult radiologist; if prep given,
do not consult radiologist):
a. Prior allergic-like contrast reaction (mild, moderate) to the same class of
contrast media agent (iodinated / gadolinium)
b. Actively asthmatic (e.g., in the ER with active asthma exacerbation)
c. Prior mild breakthrough reaction. Note: an individual radiologist may elect
to not perform the examination in this setting. This decision should be
coordinated such as during ordering/scheduling process.
5. Miscellaneous:
a. If an alternate prep has been given, consult the radiologist. If all scheduled
doses of a full steroid prep (12-13 hours) have been given but the timing is
off by 2-3 hours, no consultation is required and the scan can be performed.
The initial dose of steroids must precede contrast material administration by
not less than 4 hours.
b. Using Visipaque (iodixanol) may somewhat reduce the risk of a contrast
reaction in patients with a history of allergic-like reaction to iodinated
contrast, but the data supporting this is weak and the practice is not
required. Substituting Visipaque is not considered a substitute for
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premedication when premedication is indicated.
1. Adults:
Prednisone 50 mg (oral) q 6 hours x 3 doses starting 13 hours prior to scan:
13 hours + 7 hours + 1 hour prior to scan
Steroid Equivalences
Decadron (dexamethasone) 8 mg X 3 doses, IV or oral
OR
Solu-Cortef (hydrocortisone) 200 mg X 3 doses, IV or oral (IV preferred)
OR
Solu-Medrol (Methylprednisolone) 40 mg x 3 doses, IV or oral (IV preferred)
Total Doses required for full strength prep prior to contrast media
50 x 3 = 150 mg Prednisone
8x3 = 24 mg Decadron (Dexmethasone)
200 x 3 = 600 mg Solu-Cortef (Hydrocortisone)
40 x 3 = 120 mg Solu-Medrol (Methylprednisolone)
2. Pediatrics:
Prednisone 0.5-0.7 mg/kg PO (up to 50 mg) q 6 hours x 3 doses starting 13 hours prior to
scan: 13 hours + 7 hours + 1 hour prior to scan
Benadryl (optional) 1.25mg/kg PO 1 hour prior to scan (50 mg maximum dose)
Use the following prep when you do not have 13 hours to follow the Greenberger protocol
listed above.
1. Adults:
Solu-Medrol (Methylprednisolone) 60 mg IV Q 4 hours x 2 doses prior to contrast
administration (the first dose is given 4 hours prior to the scan and the second dose is
given before the patient is put on the CT table)
Benadryl (Diphenhydramine) 25-50 mg IV one-hour prior to scan (per Radiologist)
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I. Contrast Extravasation
1. Risk Factors:
-Non-communicative patients: infants, small children, non-English speaking and
unconscious
-Small peripheral veins (hands and feet)
-Injection of an older IV line
-Multiple attempts at IV access
-Abnormality in limb to be injected (trauma, lymphedema, etc.)
-Higher injection rates (4-5 mL/sec)
2. Sequela of Extravasations:
Iodinated contrast media is toxic to surrounding tissues/skin resulting in an acute
local inflammatory response. The vast majority of patients recover with no
significant injury.
3. Actions/Treatment:
3. Physical Exam:
-Confirm pulses in affected limb
-Assess skin color/sensation and monitor for change (compared to
unaffected limb)
-Elevate affected extremity
-Apply cold compress
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-Significant residual pain or increasing pain
-Skin changes (including blistering)
-Hardness or↓ temperature sensation at site of extravasation
-Change in sensation distal to site of extravasation
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I. Metformin Guidelines (1)
Metformin (see Appendix C for brand names) is an oral anti-hyperglycemic agent used
primarily to treat insulin resistant diabetes mellitus. The most significant adverse effect of
metformin therapy is the potential for the development of metformin-associated lactic
acidosis. Iodinated contrast media is not an independent risk factor for patients taking
metformin but is a concern only if post-contrast acute kidney injury should develop.
Category 1: In patients with no evidence of acute kidney injury and with eGFR ≥ 45
mL/min/1.73m2, there is no need to discontinue metformin either prior to or
following the intravenous administration of iodinated contrast media, nor is there
an obligatory need to reassess the patient’s renal function following the test or
procedure.
Category 2: In patients taking metformin who are known to have acute kidney
injury or chronic kidney disease (eGFR < 45), or are undergoing arterial catheter
studies that might result in emboli (atheromatous or other) to the renal arteries,
metformin should be temporarily discontinued at the time of or prior to the
procedure, and withheld 48 hours subsequent to the procedure and reinstituted
only after renal function has been re-evaluated and found to be normal. Patients
should be given written information to contact their PCP (primary care provider).
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I. Renal Insufficiency and Contrast Induced Nephropathy
The most important risk factor for CIN is pre-existing severe renal insufficiency. A
threshold of eGFR of < 30 mL/min/1.73m2 has been proposed as the limit below which
intravenous contrast administration becomes a risk factor for developing PC-AKI and
CIN(1).
II. Acute Kidney Injury Network (AKIN) definition of acute kidney injury:
III. Clinical course: The clinical course of CIN or PC-AKI depends on the baseline renal
function, coexisting risk factors, degree of hydration, and other factors. However, the usual
course consists of a transient asymptomatic elevation in serum creatinine. Serum
creatinine usually begins to rise within 24 hours of IV iodinated contrast administration,
peaks at 4 days, and often returns to baseline within 7 to 10 days. It is unusual for patients
to develop permanent renal dysfunction.
IV. Treatment: The treatment of CIN or PC-AKI is largely supportive. The major
preventative action to mitigate the risk of CIN is to provide intravenous volume expansion
(see hydration protocol, page 21). One possible protocol would be 0.9% saline at 100
mL/hr, beginning 6-12 hours before and continuing 4-12 hours after iodinated contrast
administration. This protocol is only practical in the inpatient setting.
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I. Gadolinium Contrast Use and Nephrogenic Sclerosing Fibrosis
Background
This document is a guideline for administration of intravenous (IV) contrast agents
during MRI in particular patient populations (particularly individuals with compromised
renal function) for the Department of Radiology, Duke University Medical Center. The
choices of whether to administer a contrast agent and the type of agent should ultimately
be guided by patient clinical needs. Any MRI area in which IV contrast agents (or other
medications) may be administered must have a supervising physician who is prepared for
the evaluation and treatment of idiosyncratic and allergic reactions. Such measures and
policies are not described in detail in this document.
Note that the following guidelines assume stable renal function over a period of
several months. If there is any suggestion that the patient may have sustained an acute
kidney injury, a point of care (POC) estimated glomerular filtration rate (eGFR) should be
measured within 24 hours of the scan, and the decision regarding contrast media
administration made in light of the most recent eGFR value and its trend over time. The
presence of an acute kidney injury in and of itself, regardless of the eGFR, may represent a
relative contraindication to the administration of gadolinium-based contrast agents
(GBCA).
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Patients Requiring a Serum eGFR Measurement
1) All patients >60 years old; eGFR within last 30 days.
2) All patients receiving nephrotoxic chemotherapy; eGFR since the last dose of nephrotoxic
chemotherapy.
3) Any patient with a history of renal disease, nephrectomy (complete or partial), kidney
transplant, recognized downward trend in eGFR or upward trend in creatinine; eGFR within
last 30 days or since last kidney-related intervention/event.
*Note that the above categorization system is for internal use only, and does not
correspond to the National Kidney Foundation system for staging chronic kidney disease.
Guidelines
Category 0 (eGFR ≥ 60 mL/min/1.73m2, measured within 3 months): Normal
renal function. GBCAs may be administered up to standard dosages.
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should be considered. In certain scenarios, where the future risk of development of NSF is
outweighed by the need for GBCA administration, it may be reasonable to administer a
GBCA. The following precautions must be observed:
1) A discussion of the risks and benefits must be undertaken with the referring attending
physician, and a note must be placed in the medical record by the referring attending
physician to document that the benefits of the examination are believed to outweigh the
risks.
2) For patients with eGFR < 15 mL/min/1.73 m2: A discussion of the risks and benefits
must be undertaken with the patient (or designee) by a physician member of the
Radiology department or the referring clinical team. The patient (or designee) must
provide written informed consent, and the scanned into PACS or MaestroCare. If the
consent document is obtained by the referring team but documentation cannot be
verified at the time of MRI examination, written consent must be re-obtained in MRI
prior to GBCA administration.
3) Prior to GBCA administration, the non-contrast portion of the examination must be
evaluated by a Radiologist to determine whether GBCA administration is necessary.
4) Following the above, if deemed necessary, GBCA may be administered at the lowest
reasonable dose that is expected to yield a diagnostic examination and answer the
clinical question, as determined by the supervising Radiologist. The choice of GBCA will
depend upon the clinical situation, however agents with favorable safety profiles
(MultiHance, ProHance, or Gadavist) should be used whenever possible. Magnevist is
contraindicated for patients in this category of renal function, in concordance with the
Food and Drug Administration’s guidelines.
5) The Radiologist reporting the MRI result must clearly summarize the steps taken above
in their report, including verification of informed consent (if applicable) and the note
from the referring physician.
While dialysis following GBCA administration has not shown clear benefit, the risks
and benefits of dialysis should be considered following GBCA administration to patients
who receive dialysis.
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Ferumoxytol
Ferumoxytol is an iron-based agent with no theoretical increased risk of NSF. It is a
bloodpool agent and has shown utility in vascular MRI. Use of ferumoxytol for non-
vascular indications should be avoided due to its high cost and the uncertainty of
incremental benefit from its use. The final determination regarding its suitability for use as
a contrast agent is the responsibility of the individual divisions/protocoling physicians.
Pregnancy
Gadolinium chelates may accumulate in the amniotic fluid, and the potential effects
on the pregnancy are unknown. As a result, GBCA administration is contraindicated in
pregnant or potentially pregnant patients. If it is felt necessary to administer a GBCA to
such a patient, this process is managed identically to that described for patients with
category III renal dysfunction, as above.
Breast-feeding mothers
Given the tiny amount of GBCA excreted in breast milk, the even smaller amount
expected to be absorbed by a breast-feeding infant’s GI tract, and the absence of any
evidence of toxicity to breast-feeding infants in the literature, administration of GBCA at
typical doses is considered safe in breast-feeding mothers. If a breast-feeding mother
remains concerned about potential ill effects, she may express and discard breast milk
(“pump and dump”) for 24 hours following GBCA administration to further reduce the
already small risks associated with GBCA administration.
Reference
ACR Manual on Contrast Media v10.1
http://www.acr.org/~/media/37D84428BF1D4E1B9A3A2918DA9E27A3.pdf
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I. Pregnant or Breast Feeding patient
Diagnostic iodinated contrast media have been shown to cross the human placenta
and enter the fetus when given in the usual clinical doses. In-vivo tests in animals have
shown no evidence of either mutagenic or teratogenic effects with low-osmolar contrast
media. However, no well-controlled studies of the teratogenic effects of these media in
pregnant women have been performed.
For those patients who are known to be pregnant or may be pregnant and for whom
iodinated IV or (or internal) contrast enhancement is most appropriate for performance of
the CT examination, there is no need to get signed, informed consent to use contrast media.
The data does not demonstrate mutagenic effects, fetal thyroid dysfunction or other
biological effects, including renal insufficiency. According to the ACR manual on contrast
media, Version 10.1 (2015), “given that there are no available data to suggest any potential
harm to the fetus from exposure to iodinated contrast medium by maternal IV or intra-
arterial injection, we cannot recommend routine screening for pregnancy prior to contrast
media use.” This recommendation is also supported by the FDA classification of most
iodinated contrast as Category B medications. Please also see departmental policy on use of
ionizing radiation in pregnant or potentially pregnant patients.
Gadolinium chelates may accumulate in the amniotic fluid, and the potential effects
on the pregnancy are unknown. As a result, GBCA administration is contraindicated in
pregnant or potentially pregnant patients. If it is felt necessary to administer a GBCA to
such a patient, this process is managed identically to that described for patients with
category III renal dysfunction, as above, in the previous section on Gadolinium Contrast
Use.
The available literature on the excretion into breast milk of iodinated contrast
media and the gastrointestinal absorption of these agents from breast milk is very limited.
However, several studies have shown that the expected dose of contrast medium absorbed
by an infant from ingested breast milk is extremely low. Therefore, it is safe for the mother
and infant to continue breast-feeding after receiving iodinated contrast agents. An
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informed decision to temporarily stop breast-feeding should be left up to the mother after
these facts are communicated. If the mother remains concerned about any potential ill
effects to the infant, she may abstain from breast-feeding from the time of contrast
administration for a period of 12-24 hours. There is no value to stop breast-feeding beyond
24 hours. The mother should be told to express and discard breast milk from both breasts
during that period.
Given the tiny amount of GBCA excreted in breast milk, the even smaller amount
expected to be absorbed by a breast-feeding infant’s GI tract, and the absence of any
evidence of toxicity to breast-feeding infants in the literature, administration of GBCA at
typical doses is considered safe in breast-feeding mothers. If a breast-feeding mother
remains concerned about potential ill effects, she may express and discard breast milk
(“pump and dump”) for 24 hours following GBCA administration to further reduce the
already small risks associated with GBCA administration.
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I. Pediatric Considerations
General Procedures
1. Check the computer for prior SCr value for all patients.
2. Administer the CT screening questionnaire.
3. If the history of significant kidney disease question is answered “no” and/or e-GFR
is normal, then administer Isovue 300 (unless radiologists requests Isovue 370) per
standard protocol weight-based protocol.
4. If the history of kidney disease question is answered “yes”, a Cr POC must be
ordered unless there is a SCr result available within the last 6 months. Draw SCr and
calculate e-GFR using the appropriate formula for age.
a. SCr within 6 months of contrast administration is suitable for any outpatient
without an acute history needing e-GFR calculation.
5. If e-GFR >60 ml/min/1.73 m2, administer Isovue per standard protocol.
Positive response to the history of kidney disease question and/or reduced e-GFR
1. If e-GFR <60 and >30 ml/min/1.73 m2
a. Contact radiologist to review
b. Administer Isovue at standard dose (2ml/kg) - 50% reduced dose (1ml/kg)
based on the scan indication
c. Nursing or MD will notify the ordering provider of e-GFR <60 ml/min/1.73
m2 and suggest consultation with nephrologist/urologist. Radiologist should
be available to speak to ordering provider as well if needed.
d. Document action in a nursing note.
e. If contrast is warranted administer Isovue at standard dose (<2ml/kg) per
the scan indication
Special Populations
1. All ICU patients must have a SCr drawn and e-GFR calculated within 24 hours of IV
contrast administration.
2. Patients on long-term hemodialysis do not require a SCr to be drawn. Standard dose
of Isovue will be given per standard protocol. Referring service should be notified
prior to administration.
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Emergency patients
The ordering physician can choose to bypass screening in an emergency and have IV
contrast administered without screening. This screening process bypass must be
documented by the nurse, technologist or the ordering physician. The ordering physician’s
name must be included in the documentation.
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I. Hydration protocol
1. Protocols:
a. Inpatients(1):
1. 0.9% saline at 100 mL/hr, beginning 6-12 hours before and continuing 4-
12 hours after iodinated contrast administration
OR
2. 15 mL/kg of 0.9% saline IV per hour for 6 hours prior to iodinated contrast
administration
b. Outpatients:
Outpatients who need hydration prior to and after contrast administration
should make arrangements to have this performed by the referring physician
in his/her clinic. We cannot provide intravenous or oral hydration to patients
in the radiology department.
c. Oral Hydration:
Oral hydration can be utilized but it is considered less effective than
intravenous hydration.
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I. Non-vascular Contrast Media
Contrast media may be administered into the body through the gastrointestinal
tract, genitourinary tract, cutaneous fistulae, lymphatics, and intrathecal space. Adverse
reactions to non-vascular contrast agents are rare; however, the appropriate management
of contrast media in this setting is described in this section.
II. Barium sulfate: Barium contrast agents are frequently used for outpatient
conventional fluoroscopic gastrointestinal studies and as an oral agent for some
abdominal/pelvic CT and MRI scans (Redicat, Volumen).
1. Complications:
a. Allergic-like reactions to Barium are exceedingly rare. If a patient reports a
history of allergic-like reaction to Barium, then an alternate intraluminal
agent (Isovue or Gastrografin) may be substituted. Alternatively, if the
reported reaction is mild, the patient may undergo a standard steroid pre-
medication (see pages 6-8).
b. Leakage into the pleural space, mediastinum, or peritoneal cavity: Barium
leakage can lead to mediastinitis or peritonitis and is contraindicated in
situations where extraluminal leakage is possible.
c. Aspiration: While Barium is generally inert when aspirated, large volume
aspiration can lead to inflammation or pneumonia and therefore should be
avoided in patients at risk for aspiration.
III. Iodinated contrast media: Water-soluble iodinated contrast media agents which
are specifically designed for enteric opacification can be used for certain indications. These
include, but not limited to, suspected bowel perforation, leak, or to confirm feeding tube
position.
1. Complications:
a. High-osmolar contrast media agents, e.g. Gastrografin: these agents are
hypertonic and if aspirated can cause a life-threatening pulmonary edema
and pneumonitis. These agents are contraindicated in patients at risk for
aspiration. In these patients, low-osmolar contrast media agents, e.g. Isovue,
should be substituted.
b. Allergic-like reactions to luminal administration of iodinated contrast
media are rare. Nonetheless, the potential for systemic absorption of
iodinated contrast media exists. Therefore, patients with a history of allergic
like reaction to contrast media should be treated the same as if receiving
intravenous dosing and undergo steroid pre-medication if appropriate (see
pages 6-8).
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References
1. Ellis JH CR, et al. ACR Manual on Contrast Media, Version 10.1. 2015
[cited; Available from: http://www.acr.org/quality-safety/resources/contrast-manual
2. Morcos SK. Review article: Acute serious and fatal reactions to contrast media: our
current understanding. Br J Radiol. 2005 Aug;78(932):686-93.
3. Somashekar DK, Davenport MS, Cohan RH, Dillman JR, Ellis JH. Effect of intravenous low-
osmolality iodinated contrast media on patients with myasthenia gravis. Radiology. 2013
Jun;267(3):727-34.
4. van der Molen AJ, Thomsen HS, Morcos SK, Contrast Media Safety Committee ESoUR.
Effect of iodinated contrast media on thyroid function in adults. Eur Radiol. 2004
May;14(5):902-7.
5. Elicker BM, Cypel YS, Weinreb JC. IV contrast administration for CT: a survey of practices
for the screening and prevention of contrast nephropathy. AJR Am J Roentgenol. 2006
Jun;186(6):1651-8.
6. Mukherjee JJ, Peppercorn PD, Reznek RH, et al. Pheochromocytoma: effect of nonionic
contrast medium in CT on circulating catecholamine levels. Radiology. 1997
Jan;202(1):227-31.
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Appendix A
5. If a patient has a remote history of an allergic reaction to contrast media, but has
had intervening, uneventful, contrast enhanced scans without a prep, should they
receive a pretreatment regimen with steroids?
No, in general, but these patients remain at risk for an adverse reaction. This is a
controversial area.
6. If a patient with a prior contrast media reaction has undergone a steroid prep,
what is their risk for a reaction?
The risk is lowered but a breakthrough reaction may occur.
7. If a patient has had a severe and life-threatening reaction to contrast media (such
as anaphylaxis) should we pretreat them?
We should avoid administration of iodinated contrast media to such patients. An
alternative imaging procedure should be considered. If a contrast enhanced scan is deemed
absolutely necessary, a steroid prep should be given.
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8. If a patient has had a steroid prep that differs from the Duke steroid prep, should
we cancel the study and reschedule with a Duke prep?
No. There are several appropriate steroid preps that have been recommended. It is not
clear whether one prep is advantageous over another. In these scenarios, consult the
radiologist.
If all scheduled doses of a full steroid prep (12-13 hours) have been given but the timing is
off by 2-3 hours, no consultation is required and the scan can be performed.
9. If a patient has had a prior breakthrough reaction, should they be prevented from
having another contrast-enhanced exam?
The answer depends on the severity of the reaction.
Prior moderate or severe breakthrough reaction (anaphylaxis, laryngeal edema,
hypotension): The patient should in general not be exposed to the same class of contrast
(iodinated / gadolinium), regardless of premedication
Prior mild breakthrough reaction (itching, rash, hives): The patient can safely receive
contrast if pre-medicated. An individual radiologist may elect to not perform the
examination in this setting. This decision should be coordinated such as during
ordering/scheduling process.
10. What is the likelihood that a patient will have a severe contrast reaction?
Patients with no risk factors have a risk of 4 in 10,000
Patients with a history of a prior contrast reaction have a risk of 18 in 10,000
Patients with a history of asthma have a reported risk of 23 in 10,000, but this data is likely
somewhat skewed.
Patients with a history of a prior contrast reaction that are pre-medicated have a
theoretical risk that is similar to someone with no risk factors. This has not been confirmed
experimentally.
11. If someone has a reaction history to iodinated contrast, should they be pre-
medicated before gadolinium contrast exposure (or vice versa)?
No.
12. What is the definition of a mild, moderate, and severe reaction? Are all adverse
events considered contrast media reactions?
The definitions are not set in stone, but these are the most commonly published categories:
a. Mild (prep needed) – Rash, scattered hives, mild facial swelling, sneezing, cough, nasal
stuffiness
b. Moderate (prep needed) – Mild laryngeal edema (“scratchy throat”, hoarseness), without
dyspnea, wheezing without hypoxia, diffuse urticaria, significant facial swelling
c. Severe (avoid test altogether; if no other option, prep needed) – Severe respiratory
distress, moderate or severe laryngeal edema, cardiopulmonary arrest, anaphylactic shock
(hypotension and tachycardia)
d. Not an allergic-like reaction (no prep needed) – Nausea, flushing, vomiting, sensation of
warmth
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13. What is the minimum length of an effective emergency prep?
At least four hours are required for efficacy. The data supporting this are scant, but it is
known that 1 and 2 hour steroid preps are ineffective. In cases where the clinical urgency
demands it (e.g., trauma, aortic dissection, etc.), emergency preps shorter than 4 hours may
be used at the Radiologist’s discretion.
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Appendix B
Adults:
ALL ADVERSE EVENTS
1. Stay calm
2. Obtain vital signs
3. Get help
4. Communicate with the patient (before and after treatment)
5. At conclusion, call referring physician
6. At conclusion, document in the medical record
URTICARIA:
1. No treatment needed in most cases
2. If severe: Diphenhydramine (Benadryl) 25-50 mg PO, IM, or IV
3. Patients receiving Benadryl need a driver
LARYNGEAL EDEMA:
1. Call a code (115)
2. Oxygen 10L/min by facemask
3. ADULT Epi Kit: 0.3 mL IM (1:1000 sol) repeat every 5-15 min up to
3 times. Available on Omnicell medication cart. IM is the preferred
initial treatment route.
4. Epinephrine 1-3 mL IV (1:10,000 sol); inject slowly up to 10 mL
5. Do not intubate. Use bag-mask ventilation if needed
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MODERATE/SEVERE BRONCHOSPASM:
1. Call a code (115)
2. Oxygen 10L/min by facemask
3. ADULT Epi Kit: 0.3 mL IM (1:1000 sol) repeat every 5-15 min up to
3 times. Available on Omnicell medication cart. IM is the preferred
initial treatment route.
4. Epinephrine 1-3 mL IV (1:10,000 sol); inject slowly up to 10 mL
5. Do not intubate. Use bag-mask ventilation if needed
PULMONARY EDEMA:
1. Oxygen 1OL/min by facemask
2. Elevate head
3. Stop IV fluids
4. Furosemide (Lasix) 20-40 mg IV slowly over 2 min
Pediatrics:
LARYNGEAL EDEMA:
1. Call a code (115)
2. Oxygen 6-10L/min by facemask
3. 15 - 30 kg: PEDIATRIC Epi Kit--0.15 mL IM (1:1000 sol) repeat
every 5-15 min up to 3 times. Available on Omnicell medication
cart. IM is the preferred initial treatment route.
< 15 kg: Epinephrine 0.01 mL / kg IM (1:1000 sol); max
single dose of 0.30 mL (0.3 mg); can repeat every 5-15 min up
to 1 mL total dose
> 30 kg: use ADULT Epi Kit, as above
4. Epinephrine 0.1 mL / kg IV (1:10,000 sol); inject slowly, max
single dose of 1 mL (0.1 mg); can repeat every 5-15 min up to 1 mg
total dose
5. Do not intubate. Use bag-mask ventilation if needed.
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8. Remove compression if present
MILD BRONCHOSPASM
1. Oxygen 6-1OL/min by facemask
2. Albuterol 2-3 puffs with spacer (If spacer available)
3. Do not intubate. Use bag-mask ventilation if needed
4. See below if condition worsens
MODERATE/SEVERE BRONCHOSPASM:
1. Call a code (115)
2. Oxygen 6-10L/min byfacemask
3. 15 - 30 kg: PEDIATRIC Epi Kit--0.15 mL IM (1:1000 sol) repeat
every 5-15 min up to 3 times. Available on Omnicell medication
cart. IM is the preferred initial treatment route.
< 15 kg: Epinephrine 0.01 mL / kg IM (1:1000 sol); max
single dose of 0.30 mL (0.3 mg); can repeat every 5-15 min up
to 1 mL total dose
> 30 kg: use Adult Epi Kit, as above
4. Epinephrine 0.1 mL / kg IV (1:10,000 sol); inject slowly, max
single dose of 1 mL (0.1 mg); can repeat every 5-15 min up to 1 mg
total dose
5. Do not intubate. Use bag-mask ventilation if needed.
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HYPOTENSION WITH BRADYCARDIA • VASOVAGAL REACTION
1. Oxygen 6-1OL/min by facemask
2. Raise legs 60 degrees
3. Remove compression if present
4. If mild, medications not normally needed
5. If persistent: Call a code (115)
6. Isotonic IV fluids (normal saline or Lactated Ringer's)
7. Atropine 0.2 mL/kg of 0.1 mg/mL solution IV slowly in running fluids;
minimum single dose 0.1 mg; maximum single dose 0.6-1.0 mg;
maximum total dose 1 mg for infants and children, 2 mg for adolescents
PULMONARY EDEMA:
1. Oxygen 6-1OL/min by facemask
2. Elevate head
3. Stop IV fluids
4. Furosemide (Lasix) 0.5-1.0 mg/kg; over 2 min; maximum 40 mg
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EPI-KIT Guidelines
The new policy is that IM administration will be given as the first option
for all patients (even with existing lines) with anaphylactic or potentially
anaphylactic reactions. All department Omnicells now contain epi-pen
equivalent kits for IM administration with instructions on each kit (see
picture). There is an adult kit and a pediatric kit; the weight appropriate for
the peds kit is on the kit.
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Pediatric Anaphylaxis Kit
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Appendix C
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