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Policy and Procedure Manual
Diagnostic Services – Radiology
SUBJECT/TITLE:
DS-R-05.53
INTRAVENOUS CONTRAST ADMINISTRATION
PURPOSE:
1) Ensure appropriate premedication in patients with known/suspected
allergic reactions;
2) Ensure contrast administration is performed according to hospital and
departmental protocols with appropriate supervision by a licensed
independent practitioner (LIP).
3) Ensure appropriate actions are undertaken in case of contrast reactions
and extravasation of contrast.
4) Ensure laboratory testing requirements conducted in patients in whom
contrast administration is considered.
DEFINITION:
None
BACKGROUND:
The policy will be based on the Manual on Contrast Media (ACR, 2012) and
other relevant literature.
CONTENTS:
A. Intravenous Iodinated Contrast
Preparation for Contrast Administration
Indications for Serum Creatinine
Contrast Reactions to Iodinated IV Contrast
Premedication for Iodinated IV contrast
B. Intravenous Gadolinium Based Contrast
Administration of Gadolinium
Magnetic Resonance (MR) Screening for Impaired Renal Function
Emergency MR Exams
Premedication for Gadolinium contrast
C. Intra-arterial Iodinated Contrast Administration
D. Non-Intravenous Contrast Agents
E. Ultrasound Contrast Agents
F. Pediatric IV Contrast Administration
G. Treatment of Contrast Reaction
Table 1: Suggested Treatments for Contrast Reaction
H. Treatment and Prevention of Contrast Extravasation
I. Pregnancy and Breast Feeding Precautions
J. Appendix A: Patient Information Sheet for Contrast Enhanced MRI
K. Appendix B: Patient information Sheet for Breast Feeding after Contrast Enhanced MRI
POLICY:
Guidelines for administration of Intravenous contrast:
1. A radiologic technologist or radiology nurse may administer intravenous contrast under the
supervision of a licensed independent practitioner (LIP) and in accordance with procedure
defined in this policy and following protocols used for contrast administration that are based
upon the type of examination ordered and define the type, dose and route of contrast.
2. The supervising LIP or his/her physician designee must be available to respond promptly to
an adverse event related to contrast administration.
3. Protocols for administration of intravenous contrast must be reviewed by the Department of
Pharmaceutical Care Drug Information Center and approved by the P&T Subcommittee and
by the Contrast Committee of the Department of Radiology when the standards of care and
application change or when the characteristics of the intravenous contrast change.
4. An LIP reviews all requests for radiology procedures with intravenous contrast to determine
and/or modify the appropriate protocol based on the clinical indications for the examination
and patient status. The assigned protocol is indicated in the radiology information system
(RIS) or electronic medical record (EMR).
5. A radiologic technologist or radiology nurse will review patient’s current medications and
clinical conditions for contraindications related to intravenous contrast administration. These
include allergy to contrast, use of particular medications (e.g., metformin – see below), and
general physical condition which may impact risks for patient, such as heart failure and
asthma.
6. If contraindications are identified, the supervising LIP will be contacted to determine
appropriate IV contrast use.
7. Type of contrast and dose information is recorded in the EMR by the nurse or technologist.
8. Contrast doses that are prepared and NOT immediately administered to patient by the person
who prepared the dose must be labeled with:
• Drug name, strength and amount (if not apparent from container)
• Initials or name of the person preparing the syringe
• Name of patient, medical record number, date of birth and location of the patient, if
contrast dose is prepared based upon specific patient information.
• The dose should be used immediately and not stored.
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PROCEDURE:
A. INTRAVENOUS IODINATED CONTRAST
All intravenous contrast utilized for CT and fluoroscopic exams at UIHC utilize iodine. The
differing contrast agents will vary based on the form that the iodine is organically bound. Other
variables in the type of iodinated contrast include ionic vs. nonionic, high osmolar (HOCM) vs.
low osmolar (LOCM), and iso-osmolar contrast media.
Preparation for Contrast Administration
1. Pre-administration Checks (4 Hs)
The ACR manual describes the 4 Hs
a. History
b. Hydration
c. Have equipment and expertise ready
d. Heads up
These checks have an effect on both the need for premedication, the risk of contrast extravasation,
and the need for laboratory testing.
2. Renal failure-related issues with iodinated contrast
a. Iodinated contrast has been implicated in causing significant decreased renal function in
some patients following its administration, an effect called contrast media nephrotoxicity.
b. Significant contrast media induced nephrotoxicity may be defined as:
• a >25% rise in serum creatinine from baseline (if < 1.5 mg/dl)
OR
• an absolute elevation of >1.0 mg/dl from baseline (if > 1.5 mg/dl)
within 72 hours following contrast administration.
3. Risk factors for contrast induced renal failure include:
a. Pre-existing renal insufficiency
b. History of “kidney disease” as an adult, including tumor and transplant
c. Diabetes mellitus
d. Dehydration
e. Cardiovascular disease and use of diuretics
f. Age > 60 years
g. Multiple myeloma or paraproteinemia syndromes/diseases
h. Uncontrolled Hypertension
i. Hyperuricemia (gout)
4. Medications which may increase the risk of iodinated contrast-induced renal failure.
a. Metformin (oral hypoglycemic agent for diabetes): This drug is excreted by the kidneys,
and may accumulate resulting in severe (even fatal) lactic acidosis.
b. NSAIDs including COX-2 selective agents (e.g., ibuprofen, naproxen, ketorolac,
fenoprofen, indomethacin, celecoxib, etc.)
c. Nephrotoxic antimicrobials (e.g., gentamicin, tobramycin, amikacin, amphotericin B,
cidofovir)
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5. Indications for serum creatinine prior to iodinated contrast exam
The following patients must have a serum creatinine within 60 days prior to the exam:
Age > 60
History of renal disease, including:
• Dialysis
• Kidney transplant
• Single kidney
• Renal cancer
• Renal surgery
History of hypertension requiring medical therapy
History of diabetes mellitus
Metformin or metformin-containing drug combinations
6. Measures to Prevention/Ameliorate Nephrotoxicity
a. Hydration if required. Normally, this can be achieved by oral administration of 1-2 liters
of extra fluids in the 24 hours prior to contrast injection. In some cases, this can be
achieved using 0.45% or 0.9% saline, 100 ml/hr from 12 hours before until 12 hours after
contrast administration.
b. Withhold furosemide.
c. Withhold metformin for 48 hours after contrast administration and reinstitute only after
repeat renal function tests (creatinine) had been obtained and determined to be normal.
d. In patients with risk factors for contrast-induced renal failure, administer acetylcysteine,
600 mg by mouth twice daily on the day before and on the day of contrast administration
(4 total doses).
e. In patients who present acutely and who have an indication for acetylcysteine in patients
with an adynamic ileus or non-intact GI tract, or patients who are unable to swallow and
have no NG tube, two options are allowed:
• No contrast is administered; this is the preferred option for patients who present
acutely)
• In life-threatening situations where a contrast-enhanced CT is required
immediately (e.g., suspected pulmonary embolism, suspected aortic dissection,
suspected aortic rupture, immediate requirement for vascular intervention), and
where a 24-hour delay is unacceptable based on clinical grounds, one may
consider administration of IV acetylcysteine (Acetadote® 150 mg/kg over 30
minutes immediately prior contrast administration, followed by 50 mg/kg over 4
hours after).
• If IV acetylcysteine is administered, one must to be prepared for anaphylactic
reactions and appropriate precautions much be taken.
7. Patients on Dialysis
Patients on dialysis can receive IV contrast, and early post-procedural dialysis is NOT
routinely required in every case. The Nephrology Service should be consulted for these
cases. The fact that a patient is on dialysis should NOT be regarded as automatically
allowing the administration IV contrast.
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CONTRAST REACTIONS TO IODINATED IV CONTRAST
Reactions to iodinated IV contrast occur in 1-3% of nonionic low-osmolar contrast injections.
These range from mild urticaria (hives) to severe and life-threatening events. The severe lifethreatening reactions are relatively rare. Although overall adverse reactions are decreased
following steroid premedication, the incidence of severe life-threatening adverse events has not
been affected. Therefore, administration of IV contrast in patients with previous severe reactions
should be done only in exceptional circumstances with full agreement by the patient, attending
physician(s) and radiologist.
1. Premedication
The following regimens are suggested based on the ACR Manual on Contrast media version 8.
2012:
a. Planned contrast administration in patients with previous documented/suspected reaction:
Two frequently used regimens are:
1. Prednisone 50 mg by mouth at 13 hours, 7 hours, and 1 hour before contrast
media injection, plus diphenhydramine (Benadryl ) 50 mg intravenously,
intramuscularly, or by mouth 1 hour before contrast medium.
or
2. Methylprednisolone (Medrol®) 32 mg by mouth 12 hours and 2 hours before
contrast media injection. An antihistamine (as in option 1) can also be added to
this regimen injection. If the patient is unable to take oral medication, 200 mg
of hydrocortisone intravenously may be substituted for oral prednisone.
®
b. (Semi-) acute investigations in patients with previous documented/suspected reaction:
The ordering physicians are encouraged to discuss the indication for contrast
administration with the radiologist for alternative imaging.
In decreasing order of desirability:
1. Methylprednisolone sodium succinate (Solu-Medrol ) 40 mg or
hydrocortisone sodium succinate (Solu-Cortef ) 200 mg intravenously every
4 hours (q4h) until contrast study required plus diphenhydramine 50 mg IV 1
hour prior to contrast injection.
2. Dexamethasone sodium phosphate (Decadron®) 7.5 mg or betamethasone 6
mg intramuscularly q4h until contrast study must be done in patent with
known allergy to methylprednisolone, aspirin, or non-steroidal antiinflammatory drugs, especially if asthmatic. Also diphenhydramine 50 mg
IV 1 hour prior to contrast injection.
3. Omit steroids entirely and give diphenhydramine 50 mg IV.
®
®
Note: IV steroids have been shown to be less effective when administered less than
4 to 6 hours prior to contrast injection.
c.
Pediatric pre-medication
Prednisone 0.5-0.7 mg/kg PO (up to 50 mg) 13 hours, 7 hours, and 1 hour prior to
contrast administration
AND
Diphenhydramine (Benadryl®) 1.25 mg/kg PO (up to 50 mg) 1 hour prior to contrast
administration
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d. Use of these pre-medication regimens may result in impairments that affect the
patient’s ability to drive. Appropriate precautions are advised i.e., designated driver.
e. The non-emergent patients with contrast allergy, severe enough to require premedication
may not be scanned after hours. The pre medication may be scheduled in such a way that
the patient is scanned the first thing next morning, when we have full manpower to handle
any breakthrough reactions.
f. If clinical situation warrants emergent scanning after hours in a patient who has received
either the premedication for prior contrast allergy:
• The afterhours scanning of the premedicated patient should be approved by the
faculty member during the day.
• The on-call 5-6 PM, long or short call resident (as applicable) is to be informed by
the day team about the scanning of premedicated patient.
• The technologist will page the on-call resident before administering the contrast.
• The on-call resident may request a LIP from the medical team to be present with
the patient at the time of scanning
g. On call and on weekends, any case with contrast allergy should go through the on-call
resident to determine if the study needs to be done after hours or to suggest alternative
method of scanning vs. premedication.
h. For CT studies, imaging of premedicated patients after hours may be done on the ETC
scanner if possible.
2. Emergent contrast administration in life-threatening situations
In cases of life-threatening emergency requiring administration of IV contrast and where the
ordering provider cannot wait for the premedication by the acute/semi-acute protocol requiring
administration of steroids 4 hours and 1 hour prior to the procedure and the alternative test is not
acceptable:
a. The ordering physician must add a note in the medical record of the patient prior to the
contrast administration which clearly states the following:
• Indication of the urgent study.
• Reason why the alternative exam (if offered by the radiologist) is not acceptable.
• Ensure that sufficient staff capable of handling the severe contrast reaction;
including intubation and administration of life support drugs will be available during
and after the procedure.
b. You may consider giving hydrocortisone 200 mg IV AND diphenhydramine (Benadryl®)
50 mg IV stat prior to contrast administration and 4 hours later to cover delayed reaction,
although according to the ACR manual “IV steroids have not been shown to be effective
when administered less than 4 to 6 hours prior to contrast injection.”
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B. INTRAVENOUS GADOLINIUM BASED CONTRAST AGENTS
Patients with impaired renal function who receive IV gadolinium-based contrast agents (GBCA)
for MRI or MRA exams are at risk for developing a serious side effect called nephrogenic
systemic fibrosis (NSF), previously known as nephrogenic fibrosing dermopathy (NFD). Patients
at risk for NSF are those with severe or end-stage chronic kidney disease (CKD 4 or 5) or acute
kidney injury (AKI). However, the greatest risk occurs in patients with end-stage kidney disease
on renal dialysis. Patients with AKI, the group at next greatest risk, account for 12-20% of NSF
cases. The exact NSF risk is unknown, but is probably in the range of 1-7% after one or more
exposures to IV GBCA. The FDA has issued a “black box” warning for GBCA, which requires
patients to be screened for “acute kidney injury and other conditions that may reduce renal
function.” In addition, IV GBCA can cause allergic reactions, which are biologically similar to
those observed with IV iodinated contrast agents formulated for use in CT, but are less frequent.
1. Screening for impaired renal function
a. Patients with the conditions below are at risk for impaired renal function and must have a
serum creatinine with estimated GFR (eGFR) checked prior to administration of IV
GBCA:
• Age > 60 years old
• Diabetes Mellitus (insulin-dependent, oral hypoglycemic or diet-controlled)
• History of renal disease (includes renal insufficiency or failure, solitary kidney, renal
transplant, renal tumor)
• Other conditions as deemed appropriate by the responsible radiologist
b. For outpatients with risk factors described above in subheading “a”, an acceptable time
window for prior eGFR laboratory testing, if available, is outlined in the table below
(adapted from the ACR Manual on Contrast Media, Version 8, 2012):
c. For all inpatients, eGFR level should be obtained within two days prior to GBCA
administration.
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d. Identify risk factors for AKI, including recent surgery, severe infection, severe trauma
and nephrotoxic drugs
• eGFR is not a reliable indicator of AKI.
e. Patients currently on dialysis (hemodialysis, peritoneal dialysis or continuous dialysis) do
not need to have their eGFR checked.
• Dialysis patients represent 80% of all reported NSF cases.
• The ordering provider should indicate if the patient is on continuous dialysis
(CVVHD, etc.) as these patients are at high risk for NSF, but may appear to have an
eGFR >30 mL/min/1.73m2.
2. Administration of Gadolinium contrast agents for patients with impaired renal function
a. Whenever possible, MR with IV GBCA should be avoided in patients on dialysis or with
AKI or CKD stage 4 or 5 (eGFR <30 mL/min/1.73m2). However, if imaging with GBCA
is essential and no suitable alternative is available, the following procedure must be
followed:
• The responsible radiologist and ordering physician must discuss the clinical
appropriateness, alternatives and urgency of the proposed MR exam and agree that
the benefits outweigh the risks.
• The patient will be given copy of Information Sheet for Patients Scheduled for
Contrast-Enhanced MRI. (Appendix A). The responsible radiologist will explain
the risks and benefits of the proposed MRI exam and the patient will have an
opportunity to discuss any concerns. If the patient agrees to proceed with the MRI
exam, the radiologist will obtain verbal informed consent.
• The ordering physician must add a note in the medical record of the patient prior to
the contrast administration which clearly states the benefit outweighs the risk.
• The radiology report must document the above discussions and verbal informed
consent.
• The MR exam should be performed with the smallest possible dose of GBCA
necessary to obtain a diagnostic study.
• The only permissible IV GBCA is Gadavist® (gadobutrol)). The contrast agent can
be administered only once during an imaging session.
• Omniscan (gadodiamide), Magnevist® (gadopentetate dimeglumine) and
OptiMARK® (gadoversetamide) are contraindicated in patients on dialysis or with
AKI or CKD stage 4 or 5 (per FDA warning dated 9/10/2010).
b. Try to limit the cumulative dose of GBCA over several MR exams because this may
increase NSF risk.
c. For current hemodialysis patients, dialysis should be performed as soon as possible, but no
later than 24 hours, after an MRI exam with IV gadolinium-based contrast agent.
• To date, hemodialysis has NOT been proven to decrease NSF risk.
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3. Administration of Gadolinium contrast agents for various MRI exams
a. Most contrast-enhanced MRI exams will be performed with single dose IV Gadavist®
(gadobutrol) 0.1 mmol/kg (0.1 ml/kg) body weight. If a patient has had previous contrast
reactions or nausea/vomiting to Gadavist® (gadobutrol), use Magnevist® (gadopentetate
dimeglumine) at 0.1 mmol/kg (0.2 ml/kg) if no risk of NSF.
b. Some abdominal MRI exams of the liver and biliary tree may be performed with IV
Eovist® (gadoxetate disodium) (0.2 ml/kg).
c. MR Enterography exams will be performed IV Gadavist® (gadobutrol) at 0.15 ml/kg. If
patient has a history of contrast reactions or nausea/vomiting to Gadavist® (gadobutrol),
use Magnevist® (gadopentetate dimeglumine) at 0.3 ml/kg.
d. Contrast-enhanced MRA exams will be performed with IV Gadavist® (gadobutrol) as
follows:
• Single station MRA –10 ml Gadavist® (gadobutrol).
• Two or three station MRA – 15 ml Gadavist® (gadobutrol) diluted with 25 ml saline
to 40 ml total volume.
e. Contrast-enhanced cardiac MRI exams for myocardial viability will be performed with IV
Gadavist® (gadobutrol) 0.2 ml/kg.
f. Pediatric Patients:
• Contrast-enhanced MRI exams will be performed with single dose IV Gadavist®
(gadobutrol): 0.1 ml/kg body weight in patients over 50 kg (110 lbs).
• Contrast-enhanced MRI exams will be performed with single dose IV Magnevist®
(gadopentetate): 0.2 ml/kg body weight in patients under 50 kg (110 lbs).
• MRA Neck, Brain, and MRV Brain will be performed with single dose IV
Gadavist® (gadobutrol): 0.1 ml/kg body weight in all patients diluted with saline to
equal the dose of Gadavist® (gadobutrol) for patients less than 50 kg (110 lbs).
• All other MRA’s below neck will be performed with double dose IV
Gadavist® (gadobutrol) for patients less than 50 kg (110 lbs): 0.2 ml/kg body weight
in all patients dilute with saline < dose of Gadavist® (gadobutrol) so the total volume
injected is no more than 10 ml.
• Contrast-enhanced MRA exams for patients over 50 kg (110 lbs) will be performed
with IV Gadavist® (gadobutrol) as follows:
1. Single station MRA - 10 ml Gadavist® (gadobutrol)
2. Two or three station MRA – 15 ml Gadavist® (gadobutrol) diluted to 40 ml
with saline.
• MR Enterography exams will be performed IV Gadavist® (gadobutrol) at 0.15 ml/kg
or Magnevist® (gadopentetate) 0.3 ml/kg if patient has had previous contrast
reactions to Gadavist® (gadobutrol) or nausea/vomiting.
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4. Prevention of Contrast Reactions
Allergic-type reactions to GBCA are rare and severe or anaphylactoid reactions are extremely
rare. In patients who have previously reacted to a GBCA or experienced nausea/vomiting, there
are no definitive studies to support the efficacy of premedication in reducing the incidence of
subsequent reactions. Nonetheless, in the absence of such data, it is reasonable to follow a
common sense approach.
a. Use a different gadolinium-based agent.
b. At the discretion of the radiologist, premedicate the patient with steroids and antihistamine
in accordance with the policy for iodinated contrast may be considered:
Premedication for Iodinated IV contrast (page 5)
5. Emergency MR exams (with contrast)
This section pertains to the following circumstances:
a. Request is for an emergency MR study or studies
b. Patient would ordinarily require eGFR screening for renal insufficiency
c. No current serum eGFR is available
d. The referring physician believes that a delay in performing the MR study due to obtaining
a serum eGFR would compromise patient care.
e. At the discretion of the responsible radiologist, such patients may undergo an MR exam
with Gadavist® (gadobutrol) without a current eGFR.
f. The ordering physician must add a note in the medical record of the patient prior to the
contrast administration which clearly states the benefit outweighs the risk.
g. The radiology report must document the above discussions and verbal informed consent.
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C. INTRA-ARTERIAL IODINATED CONTRAST ADMINISTRATION
1. For intra-arterial iodinated contrast injections, the same general rules apply as for intravenous
iodinated contrast injections.
2. For run-off angiograms for peripheral vascular disease, use of Visipaque® (iodixanol) may be
preferred by some (compared to Isovue® [iopamidol]) in effort to decrease the somatic effects
typical of iodinated contrast.
3. In patients with severe contrast allergy, gadolinium may be used per protocol in section B.
D. NON-INTRAVENOUS CONTRAST AGENTS
1. Oral contrast agents such as barium and diatrizoate sodium-meglumine (MD-Gastroview®,
Gastrografin®) are medications and preparation and administration must be under the supervision
of a licensed independent practitioner.
2. All procedures requiring the administration of oral contrast agents must have a written Radiology
procedure protocol that is developed by a radiologist.
3. For swallow studies, where there is an inherent risk for aspiration, non-ionic, iso-osmolar contrast
Visipaque® (iodixanol) is preferred.
4. Protocols for administration and preparation of oral contrast must be reviewed by the Drug
Information Center and approved by the P&T Subcommittee and by the appropriate radiologist or
radiologists when the standards of care and application change or when the characteristics of the
oral contrast agent change.
5. Orders for contrast administration are reviewed by a radiologist or licensed independent
practitioner to determine appropriateness. The currently used oral contrast preparations for CT,
MRI, and fluoro procedures have minimal adverse effects. A pharmacist is available on the 4JP
satellite to answer any questions the radiologist or licensed independent practitioner may have.
6. Oral contrast agents that are sent to the in-patient floor by radiology technicians must include the
following information:
a. Drug name, strength, and amount (if not apparent from the container)
b. Time and date the contrast was prepared, an expiration date, and initials of the person who
prepared the container.
c. Name of patient, medical record number, date of birth, and location of the patient.
d. Directions for use and any applicable cautionary statements. Instructions on administration
times in relation to Radiology procedure.
7. Quality control procedures are implemented to prevent retrieval errors.
a. Oral contrast is stored segregated from other medications and clearly labeled.
8. A percentage of records for cases that did not have a pharmacy review prior to dispensing are
sampled quarterly per protocol to determine if the system functions successfully as designed.
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E. ULTRASOUND CONTRAST AGENTS
Currently, there is no FDA approved ultrasound contrast agent. However, at UIHC, clinical studies
are performed under IRB and FDA guidance, for which patients will receive separate informed
consent and detailed information. Should a clinician wish to discuss such studies, he should be
directed to the responsible radiologist.
F. PEDIATRIC IV CONTRAST ADMINISTRATION
1. For iodinated contrast media agents, the same principles apply in adults as in children. The dose
of contrast is delivered based on weight of the patient (2 ml/kg).
2. For gadolinium agents, a dose is similarly prescribed based on body weight (see point 3 in
gadolinium administration paragraph). Pediatric patients (page 9)
References for pediatric contrast media use:
a. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/Contrast%20
Manual/Contrast%20Media%20in%20Children.pdf
b. http://bjr.birjournals.org/cgi/reprint/70/839/1104.pdf
c. http://www.springerlink.com/content/3211318t384ug062/fulltext.pdf
d. http://emedicine.medscape.com/article/422855-print
e. http://radiology.rsna.org/content/243/1/80.full.pdf+html
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G. TREATMENT OF CONTRAST MEDIA REACTION
In all cases, treatment should begin with:
•
•
•
•
•
IV access and monitor frequent vitals
Maintain the ABCs (airway, breathing, circulation)
Notify the radiologist
Call Code Blue, Rapid Response or 911 (at IRL) for severe reactions
Complete contrast reaction note and document allergy in EMR
• Follow up call to patient the next day (done by nursing staff and documented in EMR)
Table 1: Suggested Treatments for Adults w/ Adverse Effects to Contrast Agents
Hives
Mild
None
Observe until resolving
Moderate
(numerous &
Diphenhydramine (Benadryl®)
25-50 mg oral (causes drowsiness; patient
will need a designated driver)
bothersome to the
patient)
OR
(Scattered & transient)
Severe (profound)
Fexofenadine
180 mg po (for patients without a driver)
Secure IV access
50 mg IV Diphenhydramine (Benadryl®)
Secure IV access, IV fluids
Consider: diphenhydramine
Consider: hydrocortisone
Epinephrine
0.9% NaCl or Lactated Ringer’s 1-2 liters IV
50 mg oral or IV
200 mg IV
0.3 mg /0.3 ml IM (1:1,000), if inadequate
response;
0.1 mg/1 ml (1:10,000) slow IV; repeat as
needed up to 1 mg/10 ml total dose
Diffuse erythema
Mild
Severe
CALL CODE
Laryngeal edema
Secure IV access, O2 by mask
Epinephrine
CALL CODE
Hydrocortisone
10 l/min O2
0.1 mg/1 ml (1:10,000) slow IV; repeat as
needed up to 1 mg/10 ml total dose
200 mg IV, repeat if necessary
Bronchospasm
Mild
Moderate
Severe
Albuterol inhaler
Secure IV access, O2 by mask
Epinephrine IM*
Epinephrine IV
2 puffs, repeat as necessary
10 l/min O2
0.3 mg/0.3 ml (1:1,000) IM; may repeat once
0.1 mg/1 ml (1:10,000) slow IV; repeat as
needed up to 1 mg/10 ml total dose
CALL CODE
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Table 1 (cont): Suggested Treatments for Adults w/ Adverse Effects to Contrast Agents
Pulmonary Edema
Secure IV access
O2 by mask
Elevate head of bed
Furosemide
Morphine
CALL CODE
10 l/min O2
20-40 mg IV, slowly (≥10 mg/minute)
1-3 mg IV, repeat every 5-10 min as needed
Hypotension with Bradycardia
Mild
Severe
Elevate legs
Secure IV access, IV fluids
O2 by mask
Atropine
0.9% NaCl or Lactated Ringer’s 1-2 liters
10 l/min O2
0.6 mg – 1 mg IV, slow; up to 2-3 mg total
dose (0.04 mg/kg)
Hypotension with Tachycardia
Mild
Elevate legs
Secure IV access
IV fluids
O2 by mask
Epinephrine
0.9% NaCl or Lactated Ringer’s 1-2 liters
10 l/min O2
0.1 mg/1 ml (1:10,000) slow IV; repeat as
needed up to 1 mg (10 ml total dose)
Severe
CALL RAPID RESPONSE
Hypertension Crisis (diastolic BP > 120 mmHg)
Secure IV access
O2 by mask
Labetalol (first choice)
Furosemide (if labetalol is not
available)
Nitroglycerin
CALL RAPID RESPONSE
10 l/min O2
20mg IV over 2 minutes, may repeat q 10
minutes
40 mg IV slowly (over at least 4 minutes)
0.4 mg sublingual; repeat after 5-10 min x 3
Hypoglycemia (blood sugar below 50-60)
If patient is able to
swallow safely
Secure IV access
O2 by mask
Administer oral glucose
6-10 L/min O2
15 grams of glucose tablet/gel or ½ cup (4
oz) of fruit juice
If IV access present,
D50W IV 1 ampule (25 grams) IV push
If patient is unable to administer Dextrose 50% IV
over 2 minutes (rate 100 mL/hr)
swallow safely
If IV access not present,
1 mg (1 mg/mL) IM/SQ
administer Glucagon
Following Glucagon treatment provide a
snack
* In hypotensive patients, the preferred route of epinephrine delivery is IV as the extremities may not
be perfused sufficiently to allow adequate absorption of IM administration
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H. TREATMENT AND PREVENTION OF CONTRAST EXTRAVASATION
Methods to Decrease the Risk of Extravasation during Injection of Contrast Media
1. Most CT and MRI protocols use power injectors. In angiography/intervention there is a mix of
power and hand injections. There is preference for 20-gauge or larger catheters/cannulas with
flow rates of 3 ml/second or higher.
2. Extravasations have incidence of 1/1000 to 1/106 patients when a power injector is used.
3. Patients should be instructed about potential extravasation and how to alert the technician. All
injections should be monitored during the first 10-15 seconds of injection to ensure no
extravasation occurs early. Communication with the patient should continue via intercom during
injection.
4. Use of standard central venous catheters should be discouraged, but Power PICC lines (purple)
and Power Ports may be used for contrast injection should the situation demand it.
5. Extravasation of MRI contrast media is rare and generally constitutes relatively small quantities,
thus limiting the risk for compartment syndrome.
6. Extravasation of any contrast volume should be treated in accordance with the following
paragraphs.
7. Risk factors that have been identified for contrast extravasation include:
a. Inadequate communication (elderly, altered consciousness)
b. Severely ill/debilitated patients
c. Patients with abnormal circulation to limb to be injected (atherosclerosis, Raynaud‘s
disease, venous thrombosis/insufficiency, prior radiation therapy, previous [axillary]
surgery)
d. More peripheral injection sites (hand, wrist, foot, ankle)
e. Injection through line that has been present >24 hrs
Treatment of Extravasation of IV Contrast Media
1. Observation is required if extravasation <100 ml low osmolar contrast media:
a. Notify radiologist.
b. Elevate affected limb above the heart. Check the pulses and sensations.
c. No clear evidence favoring the use of warm or cold packs ( ACR manual 2010).
Suggested applying cold pack for immediate relief of pain and burning x 30 minutes
followed by warm pack x 12-24 hours to facilitate absorption of the contrast.
d. If >5 ml extravasated: observation for 2-4 hours.
e. The radiologist may at his/her discretion discharge a patient less than 2-4 hours with
gadolinium agent extravasation. The guidelines for IV contrast media extravasation may
be referred to as needed.
f. Watch for increasing pain, swelling, blisters, numbness or tingling.
g. Disposition to be determined by the radiologist or the LIP.
h. Record the event and the treatment in the patients chart.
2. Surgical (plastic surgery) consultation is required in the following situations:
a. Extravasation >100 ml low-osmolar contrast media.
b. Increased swelling or pain after 2-4 hours.
c. Altered tissue perfusion.
d. Change in sensation or temperature.
e. Development of skin ulceration or blistering.
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I. PREGNANCY AND BREAST FEEDING
Pregnancy
1. During pregnancy, it is safe practice to limit ionizing radiation as well as MRI investigations as
much as possible. Nevertheless, the risk of missing a diagnosis or mismanagement in the absence
of a significant diagnosis will take precedent over any risks to the mother and fetus.
2. The administration of iodinated contrast and oral contrast agents has no known risks during any
trimester.
3. For gadolinium-based contrast agents there is insufficient data at present, and therefore these
agents should NOT be routinely administered during pregnancy.
a. The decision to use intravenous contrast must be made on a case-by case basis by the
attending radiologist, who will confer with the referring physician to assess the risk–
benefit tradeoffs for that patient. The medical necessity to use contrast during pregnancy
must be documented in the patient’s medical record by the attending physician who
requested the study must be in the patient’s medical record before procedure can be
performed.
b. If it is determined that contrast is needed, the patient or legal guardian must sign a
procedural consent form (G-2d2) after they are made aware of the potential risks and
benefits of the proposed MR procedure and the availability of alternative diagnostic tests
(if any).
Breast Feeding
The literature on the excretion into breast milk of iodinated and gadolinium-based contrast media and
the gastrointestinal absorption of these agents from breast milk is very limited; however, several
studies have shown that 1) less than 1% of the administered maternal dose of contrast medium is
excreted into breast milk; and 2) less than 1% of the contrast medium in breast milk ingested by an
infant is absorbed from the gastrointestinal tract. Therefore, the expected dose of contrast medium
absorbed by an infant from ingested breast milk is extremely low.
1. Iodinated contrast agents are excreted rapidly through the kidneys, and less than 1% is
excreted into breast milk during the first 24 hours. Therefore, it is considered safe for the
mother to continue breast feeding after receiving iodinated contrast.
2. Gadolinium contrast is excreted rapidly through the kidneys, and less than 0.04% is excreted
into breast milk during the first 24 hours. Therefore, it is considered safe to continue breast
feeding after receiving Gadolinium contrast. Patients will be given the Breast Feeding
Information Form (Appendix B) prior to their MRI procedure.
3. If the patient has any question or concerns they can speak to a radiologist.
4. If the patient still has concerns they can pump and throw their milk away for the next 24 hours
after their injection of gadolinium.
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J. APPENDIX A: INFORMATION SHEET FOR CONTRAST ENHANCED
MRI
Information Sheet for Patients Scheduled for Contrast-Enhanced MRI
Your doctor or health care provider has ordered a Magnetic Resonance Imaging (MRI) test with
intravenous contrast to help evaluate your medical condition. The MRI contrast contains a metal
called gadolinium, which increases the diagnostic capability of MRI. Unlike the “x-ray dyes” used for
CT scans, MRI contrast agents do not contain iodine and have enjoyed a generally excellent safety
profile after 20 years and more than 200 million doses worldwide. However, recent reports in the
medical literature have identified an association between gadolinium contrast and a rare, debilitating
disease called Nephrogenic Systemic Fibrosis (NSF). First described in 1997, NSF can affect the
skin, muscles, and internal organs. The skin can become thick, hard, tight, dark and itchy. NSF occurs
exclusively in patients with severely impaired kidney function, particularly those on kidney dialysis.
The disease is rarely fatal, but there is no consistently successful treatment. The cause of NSF and the
exact role of gadolinium contrast are unknown. In patients with severely impaired kidney function,
the risk of developing NSF from gadolinium contrast is not precisely known, but is probably small (37%). After carefully considering your medical condition, your doctor and the supervising radiologist
believe that an MRI with gadolinium contrast is medically indicated and is more likely to provide
important diagnostic information than alternative imaging tests. Also, your doctors believe that the
potential benefits of MRI with gadolinium contrast outweigh the risks. To minimize your chances of
developing NSF, your radiologist will perform the MRI with one of three gadolinium contrast agents
thought to pose a smaller risk of NSF. We will use the lowest possible contrast dose consistent with
making a diagnostic study. If you are currently on hemodialysis, you will be dialyzed promptly after
your MRI to help remove the gadolinium contrast from your body. The US Food and Drug
administration (FDA) cautions that all gadolinium contrast agents may pose a risk of NSF.
Your radiologist, who is a physician with expertise in medical imaging, will be glad to answer any
questions or concerns that you may have about your MRI or the intravenous contrast agent.
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K. APPENDIX B: BREAST FEEDING INFORMATION FORM
University of Iowa Hospitals and Clinic
Department of Radiology
MRI
0440 JCP
200 Hawkins Drive
Iowa City, Iowa 52242-1077
319/356-2236
319/353-7886 Fax
Your doctor as ordered an MRI exam that requires us to give you a gadolinium contrast
agent for this exam. Gadolinium is a type of contrast agent that will be injected in a
vein in your arm and will give the radiologist additional information when reading
your images. After injection of the gadolinium contrast agent a tiny amount will be
excreted into your breast milk. A review of the literature shows there is no evidence to
suggest that the oral intake of your breast milk by your baby that contains the tiny
amount of gadolinium would cause toxic effects to your baby. It is believed that the
available data suggest that it is safe for you to have your baby continue breast feeding
after receiving an injection of gadolinium contrast agent. If you remain concerned
about any potential ill effects, you can speak to a radiologist so you can make an
informed decision as to whether to continue breast-feeding or temporarily stop breastfeeding after receiving a gadolinium contrast agent. If you so desire, you can stop
breast-feeding for 24 hours and pump both breasts if needed and throw the pumped
breast milk away. After 24 hours you can resume normal breast feeding. If you have
any questions and would like to speak to a radiologist please ask the receptionist.
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Reviewed by Department of Pharmaceutical Care (March 2012, March 2013)
Reviewed by Department of Anesthesiology (April 2005)
Approved by the Pharmacy and Therapeutics Subcommittee (March 2012, March 2013)
Approved by Radiology Quality Assurance Committee (March 2012, January 2013)
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