Download Standard Operational Procedure for administration of intravenous

Standard Operational Procedure for
administration of intravenous iodinated
contrast medium by Radiographers
Title of SOP:
Standard Operational Procedure for administration
of intravenous iodinated contrast medium by
Radiographers
Dates:
April 2012
Issue Date:
Purpose and Background
(ie Policy Statement and Background):
Background
Injection of intravenous (IV) Iodinated contrast medium
is used routinely in CT scanning for opacification of
vascular structures and organs, allowing improved
visualisation of anatomy and some pathologies.
Injection is via a cannula (inserted as per department
SOP) and may be
 A hand injection ( usually a bolus of 50ml)
 Via the pressure injector (usually 100-150ml)
Though adverse reactions are generally mild and self
limiting more severe life threatening reactions can
occur. The individual administering the pharmaceutical
must be aware of risk factors in order to minimize
adverse reactions and should they occur, know how to
promptly recognise and manage them.
Side Effects
Reactions are infrequent and may be mechanical or
physiological.
Mechanical:
 Extravasation of contrast may occur with either
method of delivery of IV contrast but may have
more serious sequela when the pressure
injector is used, due to the pressure, volume of
contrast and remote operation of the system.
 Air Embolism is a rare complication.
Physiological
Anaphylactoid – more common in patients with history
of previous contrast reaction and asthma, though
anxiety and fear have an effect. Anaphylactoid
reactions usually occur within 20 minutes of the
injection but may occur with a delay of some hours and
are independent of the dose administered.
Symptoms classified in three groups:
 Mild – skin rash, itching, nasal discharge,
nausea, vomiting
 Moderate – persistence of mild symptom, facial
or laryngeal oedema, bronchospasm,
dyspnoea, tachycardia or bradycardia.
 Severe – Life threatening arrhythmias,
hypotension, overt bronchospasm, laryngeal
pulmonary oedema, seizure, syncope, death.
Nonanaphylctoid Reactions
Result from the ability of the contrast media to upset
homeostasis of the body. Larger volumes and route of
administration affect the risk.
Symptoms:
 Warmth, metallic taste, nausea, vomiting,
bradycardia, hypotension, vasovagal reactions,
neuropathy and delayed reactions.
Contrast induced nephropathy (CIN)
Acute renal failure which occurs within 48 hours of
administration of iodinated contrast, which is not
attributable to other causes.
Risk is increased in patients with with pre-existing renal
dysfunction and those with concurrent conditions and
medications which may affect renal function.
To minimise side effects and optimise patient care
Radiographers administering intravenous contrast
must adhere to the following standard operational
procedure.
Scope (i.e. organisational responsibility)
Vital functions affected by this SOP:
This document applies to all Radiographers when
administering IV iodinated contrast during CT
examinations.
Escalations (if you require any further
clarification re the process outlined
please contact):
CT Lead Radiographer
Senior Radiographer of the day
Clinical Lead in Radiology
Author:
Angela Smith CT Lead Radiographer
Section 2: Operating Procedure
1. The radiographer must have completed a recognised IV cannulation course and completed
the departmental record of practical training. (Appendix 2)
2. The radiographer must be up to date with the Trust mandatory training in resuscitation.
3. A Patient Group Directive (PGD) for each contrast agent/drug to be injected must be signed by
the Radiographer following appropriate training.
 Optiray 300 mg iodine/ml (active ingredient ioversol)
 Visipaque 270mg/ml (active ingredient iodixanol)
 Niopam 300mg/ml ( active ingredient iopamidol)
4. The Radiographer must complete the departmental training for the use of the power injector
5. Between the hours of 9am – 5pm Monday to Friday a Radiologist must be in the department
when delegation of this duty occurs, to provide advice and cover in the event of an adverse
reaction.
6. Between the hours of 5pm and 9am Monday to Friday, and 5pm on Friday until 9am on
Monday all inpatients referred for a contrast CT must be accompanied by a member of staff
from the referring ward/team. In the event of a suspected evolving adverse reaction medical
staff from A/E department will provide support. Advice on the appropriateness of IV contrast in
high risk patients must be sought from the on-call Radiologist.
7. Radiographers must only administer injections to adults (16 years and above).
8. The pharmaceutical and its dose should be given by the radiographer in accordance with
established departmental protocols, or as individually advised by the supervising Radiologist.
9. The Safety Questionnaire for Outpatients Undergoing CT Scanning or the Checklist for
inpatient CT scans must be completed: (Appendix 1)
10. To minimise the risk of CIN all patients must be well hydrated prior to administration of
iodinated contrast.

Out patients –
 all out patients attending for Iodinated contrast CT examinations will be advised to
drink 500ml water over the hour proceeding their CT appointment. Information is also
given to hydrate ( 1 litre of water over 24 hours) after the scan.
 On arrival at the department a further 500ml water is given to support hydration.
 On completion of the scan the Radiographer must reiterate the post scan hydration
advice. Drink 1 litre of water over the next 4-6 hours.

Inpatients –
 if eGFR is between 30-60 inpatients must be hydrated prior to CT. The clinicians must
assess individually and ensure that hydration is optimised. The following regime is a
recommendation only.
 IV hydration – Normal saline at 100ml/hour for 4 hours prior to the CT study and for
12 hours after the study at the same rate.
 Oral hydration – 500ml of fluid 2-4 hours prior to the CT study and 2.5L over the 24
hours following.
11. If the patient reports a history of severe allergic reaction to any substance, the supervising
Radiologist must be consulted before proceeding.
12. If the patient has poorly controlled asthma, which has required recent hospitalisation consult
the supervising Radiologist before proceeding.
13. If the patient is known to suffer from any of the conditions stated on the Safety Questionnaire
consult the supervising Radiologist before proceeding.
14. Check renal function on all inpatients and outpatients known to have a renal problem.
15. Renal Function parameters and iodinated contrast:
 eGFR greater than 60 – proceed with iodinated contrast
 eGFR between 30-60 – implement hydration policy ( see 13 above)
 eGFR below 30 – discuss with Radiologist before proceeding
16. Emergency Drugs must always be available in the room
17. A second member of staff must be available to assist whilst an injection is taking place:
 To observe the injection site for extravasations
 To assist if an emergency situation arises
18. If extravasation occurs:
 Abort the injection immediately
 Assess the pulse distal to the injection site
 Manage small extravasations by removing the cannula, elevating the limb and applying
a cold compress.
 Larger volumes (50ml +) inform the supervising Radiologist.
19. If a patient has an adverse reaction, however mild, one member of staff must stay with the
patient whilst the second informs the supervising Radiologist.
20. Any adverse reaction must be documented on CRIS and for inpatients, in the notes.
21. Type/quantity and batch number of all injection must be checked by two members of staff
22. Following injection with iodinated contrast the patient must not be left unsupervised for 5
minutes and must remain in the department for at least 20 minutes. The patient must be
advised to stay within the hospital for 1 hour following the injection and not to drive for 1 hour
following the injection.
23. Patients who are deemed to be higher risk should remain in the department for at least 30
minutes post injection.
24. Saline may be injected by the Radiographer to check and maintain patency of the cannula
25. ALL DOCUMENTATION MUST BE COMPLETED ON THE APPROVED FORM AND
SCANNED INTO THE PATIENTS’ FILE ON CRIS
Appendix 1
Safety Questionnaire for Patients Undergoing CT Scanning
Your doctor has asked us to perform a CT Scan. This involves the use of x-rays and an intravenous
injection of contrast (dye). It is important that you complete the following information prior to your
scan. Please hand the completed form to the CT Radiographer at the time of your appointment.
Name
Date of Birth
Checklist – Do you suffer from any of the following:
Have you had x-ray contrast before?
Severe allergies
Asthma (which has required you to be bought into
hospital in the last 12 months)
Diabetes which is treated with Metformin
Kidney problems
Hepatic disease
Myeloma
Hyperthyroidism / treatment with radioactive iodine
Phaeochromocytoma
Anuria (Unable to pass urine)
High or low blood pressure
Congestive heart failure
Myasthenia Gravis
Yes
No
Comment
eGFR…….. Date………..
Female Patients Only
Are you pregnant or breast feeding?
When was the first day of your last period?
By signing below you acknowledge that your personal details are correct and that you have answered
the questions to the best of your knowledge.
Signed:
Date:
Staff Only
Bowel Preparation
Yes No
Contraindications
Comments
Quantity
Batch
Expiry
Bladder emptied prior to scan
Yes No
CT Urogram
Contraindications
Furosimide
CTC
Buscopan
Initial
An appropriately qualified member of staff must sign to confirm that they have followed the correct identification procedure,
as per IR(ME)R and checked all appropriate contraindications to comply with Macclesfield District General Hospital Patient
Group Directives.
Signed:
Cannulation Record
Inserted at ……………………………hrs
Date:
by…………………………. Position………………………….Guage……………….
Attempts……………………………………………………………………..
Removed at………………………….hrs
by…………………………..
Aseptic Technique………….........
Checklist for Inpatient CT Scans
These checks MUST be completed when Intravenous Iodinated Contrast is required
Patient ID
Date/ Time
of Scan
Renal
Function:
eGFR ml/min:
Date of result:
If this patient’s eGFR is <= 60 ml/min then your patient is at significant increased risk of
CONTRAST INDUCED NEPHROPATHY (CIN). CIN is associated with much higher subsequent
patient morbidity and death. Optimal hydration if eGFR < 60 ml/min is indicated to minimise
risk.
ONE of the following IV or ORAL hydration regimes are suggested for eGFR 30-60 ml/min.
Patients with eGFR <30 ml/min should be discussed with a Radiologist
Oral hydration – 500ml of fluid 2-4 hours prior to the
CT study and 2.5L over the 24 hours following.
yes
no
IV hydration – Normal saline at 100ml/hour for 4
hours prior to the CT study and for 12 hours after the
study at the same rate.
yes
no
Please indicate an alternate regime or clinical urgency preventing pre-scan hydration as follows:
Is there a history of:
Any known allergies
Asthma (requiring recent hospital admission)
Myeloma
Myasthenia Gravis
Pheochromocytoma
Glaucoma
Cardiac arrhythmia
Urinary Retention
Metformin Therapy
Does the patient require barrier nursing?
Has information been given to the patient regarding
their scan
Has the patient been prepared according to the
protocol overleaf
Female Patients LMP
yes
yes
yes
yes
yes
yes
yes
yes
yes
no
no
no
no
no
no
no
no
no
yes
yes
no
no
yes
no
Name and designation of person completing the
checklist: =>
Signature
Date and Time
Section 4: Standing Operating Procedure (SOP) Back Up Information
Document Change History:
Replacing Existing Policy
Approval Record:
Committee/Group
Date
Radiology Departmental Meeting
Roles and Responsibilities:
It is the responsibility of the CT Lead Radiographer to make this
policy available to all staff working in the CT Suite. It is the
responsibility of all staff working in the CT department to familiarise
themselves with this policy and to implement it where appropriate
Measuring Performance:
Audit:
After 12 months
Definitions:
None
References:
Contrast –Induced Nephropathy T Gleeson, S Bulugahapituija 2004
American Journal of Roentgenology
Iodinated Contrast Media and their adverse reactions. J Sing. A
Daftary 2008 Journal of Nuclear Medicine Technology Vol36.2.69-74
Optiray 300 Technical Leaflet. Malinckrodt Medical Imaging. Ireland
RCR (2005) Standards for Iodinated Contrast Agent Administration
to Adult Patients
Visipaque 270 Technical Leaflet . GE Healthcare. England
Niopam 300 Technical Leaflet Bracco England
Review Date:
July 2014
Policy Title: Standard Operational Procedure for connecting InPatients to the pressure injector prior to contrast enhanced CT
scan
Directorate: SBU
Name of person/s auditing / authoring policy: Sara Rathmill. Service Development Manager Radiology
Policy Content:

For each of the following check whether the policy under consideration is sensitive to people of a different age, ethnicity,
gender, disability, religion or belief, and sexual orientation?

The checklist below will help you to identify any strengths and weaknesses of the policy and to check whether it is
compliant with equality legislation.
1. Check for DIRECT discrimination against any minority group of PATIENTS:
Action
Question: Does the policy contain any statements which
Response
required
may disadvantage people from the following groups?
Yes
1.0
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
Age?
Gender (Male, Female and Transsexual)?
Learning Difficulties / Disability or Cognitive Impairment?
Mental Health Need?
Sensory Impairment?
Physical Disability?
Race or Ethnicity?
Religious Belief?
Sexual Orientation?
No
x
x
x
x
x
x
x
x
x
Yes
No
Resource
implication
Yes
x
x
X
X
x
X
X
X
X
No
x
x
X
x
X
X
X
X
x
2. Check for DIRECT discrimination against any minority group relating to EMPLOYEES:
Action
Resource
Question: Does the policy contain any statements which
Response
required
implication
may disadvantage employees or potential employees from
Yes
No
Yes
No
Yes
No
any of the following groups?
x
x
x
Age?
2.0
x
X
X
2.1 Gender (Male, Female and Transsexual)?
X
X
X
2.2 Learning Difficulties / Disability or Cognitive Impairment?
X
X
X
2.3 Mental Health Need?
X
X
X
2.4 Sensory Impairment?
X
X
X
2.5 Physical Disability?
X
X
X
2.6 Race or Ethnicity?
X
X
X
2.7 Religious Belief?
x
x
x
2.8 Sexual Orientation?
TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING DIRECT DISCRIMINATION = 0
3. Check for INDIRECT discrimination against any minority group of PATIENTS:
Question: Does the policy contain any conditions or
requirements which are applied equally to everyone, but
disadvantage particular people because they cannot
comply due to:
3.0 Age?
3.1 Gender (Male, Female and Transsexual)?
3.2 Learning Difficulties / Disability or Cognitive Impairment?
3.3 Mental Health Need?
3.4 Sensory Impairment?
3.5 Physical Disability?
3.6 Race or Ethnicity?
3.7 Religious, Spiritual belief (including other belief)?
3.8 Sexual Orientation?
Response
Yes
No
Action
required
Yes
No
x
X
X
X
X
X
X
X
x
Resource
implication
Yes
x
X
X
X
X
X
X
X
x
No
x
X
X
X
X
X
X
X
x
4. Check for INDIRECT discrimination against any minority group relating to EMPLOYEES:
Action
Resource
Question: Does the policy contain any statements which
Response
required
implication
may disadvantage employees or potential employees from
Yes
No
Yes
No
Yes
No
any of the following groups?
X
X
X
Age?
4.0
X
X
X
4.1 Gender (Male, Female and Transsexual)?
X
X
X
4.2 Learning Difficulties / Disability or Cognitive Impairment?
X
X
X
4.3 Mental Health Need?
X
X
X
4.4 Sensory Impairment?
X
X
X
4.5 Physical Disability?
X
X
X
4.6 Race or Ethnicity?
X
X
X
4.7 Religious, Spiritual belief (including other belief)?
x
x
x
4.8 Sexual Orientation?
TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING INDIRECT DISCRIMINATION = 0
Signatures of authors / auditors:
Date:11/7/2011
Equality and Human Rights Compliance / Percentage Calculation
Number of ‘Yes’ answers for DIRECT discrimination.
(A) 0
Number of ‘Yes’ for INDIRECT discrimination.
(B)0
Total answers for POLICY CONTENTS discrimination.
(A+B)0
Percentage content non compliant
=
100)
0
(Divide a+b by 36 x