Intravenous contrast media for ct procedures

Mount Sinai Hospital/University Health Network/
Women’s College Hospital
Policy & Procedure Manual
Department of Medical Imaging – Intravenous
Contrast Media for CT Procedures
The Department of Medical Imaging uses intravenous (IV) contrast media in certain computed tomography (CT) procedures to enhance anatomy.
IV contrast may be administered only on the order of a physician and by staff who have completed the required The process for obtaining patientassociated with the IV injection of contrast is standardized for every patient.
is required in cases of impaired renal function, previous contrast reaction, and other specified conditions.
of contrast are prepared according to standard guidelines.
Staff involved in the use of IV contrast media must maintain their knowledge of potential and how to respond to them. They must also be able to manage the situation when contrastoccurs. Refer to thepolicy 16.40.002.
Contrast Administration Guidelines & Training
Medical radiation technologists (MRTs) may administer contrast media provided that: • The technologist has completed an approved course of instruction and • The radiologist or other qualified physician supervising the procedure is available to intervene in the treatment if any complications arise from the injection.
Medical Directive for Administration of Benadryl®
A medical directive exists that al ows qualified MRTs to administer oral Benadryl® for the relief of a symptomatic rash or hives resulting from the IV injection of contrast. The directive applies to MRTs who have completed an educational in-service on contrast This material has been prepared solely for use at Mount Sinai Hospital (MSH), University Health Network (UHN) and Women’s College Hospital (WCH). MSH/UHN/WCH accept no responsibility for use of this material by any person or organization not associated with MSH/UHN/WCH. No part of this document may be reproduced in any form for publication without permission of MSH/UHN/WCH. A printed copy of this document may not reflect the current, electronic version on the MSH/UHN/WCH Intranet.
16.30.003
Patient Care
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Radiologist-in-Chief
reactions and Benadryl®, and have signed the medical directive signature form. Patients who receive Benadryl® are given a Benadryl® Information Sheet.
Selection of Technologists
A technologist will be considered for qualification in the administration of contrast media if: • He/she holds an up-to-date certificate in CPR. This certificate must not be • He/she has successful y completed the course in intravenous administration techniques offered by the Michener Institute or an approved equivalent (e.g., by a previous employer).
• He/she is immunized for hepatitis B (optional but encouraged).
Practice Guidelines
Note: The fol owing Practice Guidelines were developed based on the col ective
knowledge and experience of the Joint Department of Medical Imaging. The Guidelines are reviewed and revised on an ongoing basis to reflect changes in knowledge and practice. The Practice Guidelines exist to provide guidance for the safe and efficient administration of IV contrast for the majority of clinical circumstances. Unique or exceptional circumstances wil arise that are outside of the scope of the Practice Guidelines. In these circumstances, the risks and benefits of the administration of IV contrast wil need to be weighed on an individual basis.
The technologist administering contrast media is responsible for knowing and understanding the procedures and ramifications of this act. These include: • the type of contrast media being used, including its risks and the risk management associated with its injection and use • an awareness of the location of the nearest crash cart and contrast reaction • patient identification requirements as per the • patient assessment, including the contrast media injections checklist: This material has been prepared solely for use at Mount Sinai Hospital (MSH), University Health Network (UHN) and Women’s College Hospital (WCH). MSH/UHN/WCH accept no responsibility for use of this material by any person or organization not associated with MSH/UHN/WCH. No part of this document may be reproduced in any form for publication without permission of MSH/UHN/WCH. A printed copy of this document may not reflect the current, electronic version on the MSH/UHN/WCH Intranet.
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Training Program
The training program and requirements include: • successful completion of an approved course in intravenous techniques • successful completion of an approved course in contrast materials and • observation/supervision by a radiologist or designate of six successful injection • successful pass of a written quiz as determined by a radiologist or designate Documentation
Proof of completion of the requirements wil be placed in the technologist’s file.
Radiologist Involvement
Radiologist involvement is required in cases of: • diabetes (treated with medication) with abnormal renal function • contrast injection within the past 72 hours • previous contrast reaction or multiple al ergies • special circumstances as outlined below
• Special Circumstances
In each circumstance, the risks and benefits of IV contrast should be careful y considered for the individual patient. Consideration should be given to other means of investigation, if appropriate.
Reaction to previous contrast injections or multiple allergies –
Note: Research has shown that premedication prior to contrast
administration may decrease the risk of a repeat reaction. However, premedication does not eliminate the risk of a repeat reaction. If a This material has been prepared solely for use at Mount Sinai Hospital (MSH), University Health Network (UHN) and Women’s College Hospital (WCH). MSH/UHN/WCH accept no responsibility for use of this material by any person or organization not associated with MSH/UHN/WCH. No part of this document may be reproduced in any form for publication without permission of MSH/UHN/WCH. A printed copy of this document may not reflect the current, electronic version on the MSH/UHN/WCH Intranet.
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Radiologist-in-Chief
repeat reaction occurs despite premedication, it is usual y of the same severity as the index reaction. The radiologist may also recommend premedication for patients with known multiple al ergies.
Premedication – elective: The premedication protocol is as fol ows:
prednisone 50 mg PO 13 hours and 1 hour pre-examination and
Benadryl® 50 mg PO 1 hour pre-examination. Staff must inform the
patient that Benadryl® may cause drowsiness and the patient
should arrange to be driven to and from the appointment. (See also
theinformation sheet.) At the
discretion of the radiologist, a different contrast agent may be used.
Premedication – emergency: If premedication is required under
emergency circumstances, the fol owing regimen is recommended:
diphenhydramine 50 mg IV, 1 hour prior to injection. The additional
use of steroids may be considered. However, steroids wil not be
effective unless given at least 4 hours before the injection of IV
contrast. At the discretion of the radiologist, Solu-Medrol® 40 mg IV
or Solu-Cortef® 200 mg IV may also be administered. At the
discretion of the radiologist, a different contrast agent may be used.
Renal insufficiency – Patients with decreased estimated glomerular
filtration rate (eGFR), diabetes, increased age, and dehydration are at
greatest risk of developing contrast-induced nephropathy (CIN). When an
eGFR level is required, it must have been obtained within the previous
three months. Inpatients with a history of renal disease or diabetes must
have an eGFR within seven days prior to receiving contrast.
If required, eGFR can be calculated from a creatinine level using the calculator found at http://mdrd.com/ (must use SI units).
Iodixanol (Visipaque™) is currently being used for CT throughout MSH, UHN, and WCH. IV contrast is considered safe from a renal perspective provided iodixanol is used, and the eGFR is as fol ows: for patients without diabetes: greater than 30 mL per min per 1.73 m2 for patients with diabetes: greater than 50 mL per min per 1.73 m2 If the eGFR is less than the above, consultation with the referring
physician may be required to assess the risks and benefits of IV contrast
in each patient.
If IV contrast is to be given in this situation, patients should be well
hydrated before and after contrast injection and receive acetylcysteine
(Mucomyst®). The recommended hydration protocol is:
This material has been prepared solely for use at Mount Sinai Hospital (MSH), University Health Network (UHN) and Women’s College Hospital (WCH). MSH/UHN/WCH accept no responsibility for use of this material by any person or organization not associated with MSH/UHN/WCH. No part of this document may be reproduced in any form for publication without permission of MSH/UHN/WCH. A printed copy of this document may not reflect the current, electronic version on the MSH/UHN/WCH Intranet.
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Radiologist-in-Chief
Normal saline 300 mL for 1 hour pre-CT and normal saline 200 mL per hour for 3 hours post-CT administration of acetylcysteine (Mucomyst®) 1,200 mg twice a day by mouth the day before and the day of the IV contrast injection may help to preserve renal function Note: For urgent cases, acetylcysteine IV 1200 mg then 1200 mg twice a
day by mouth for 48 hours fol owing injection is recommended.
If the eGFR is less than the above, consideration should also be given to
reducing the volume of IV contrast that would normal y be administered.
Patients on dialysis – If a patient stil has urine output, consult with the
physician providing dialysis with regards to the necessity of IV contrast.
Otherwise, it is not necessary to coordinate IV contrast administration with
dialysis.
Patients with diabetes who are taking metformin-containing
medication (e.g., Glucophage®).
Common metformin-containing medications include: For an extensive list of metformin-containing products, refer to the UHN Intranet database MicroMedex (see Clinical Tools at http://intranet.uhn.ca/clinical_tools/).
If the eGFR is greater than 60 mL per min, the patient may continue to take metformin.
If the eGFR is less than 60 mL per min, metformin should be stopped for 48 hours after the injection. If there is any change in the urine output, the eGFR should be checked by the referring physician before restarting metformin. The patient should be given asheet.
If the eGFR is less than 30 mL min and IV contrast is injected, the patient
should be hydrated according to thepreviously
outlined, and metformin should be stopped 48 hours prior to contrast
This material has been prepared solely for use at Mount Sinai Hospital (MSH), University Health Network (UHN) and Women’s College Hospital (WCH). MSH/UHN/WCH accept no responsibility for use of this material by any person or organization not associated with MSH/UHN/WCH. No part of this document may be reproduced in any form for publication without permission of MSH/UHN/WCH. A printed copy of this document may not reflect the current, electronic version on the MSH/UHN/WCH Intranet.
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injection and restarted only at the discretion of the referring physician. Contrast is administered according to routine protocol unless instructed otherwise by a radiologist.
Pregnant patients – The risk/benefit ratio of performing a contrast-
enhanced study on a pregnant patient should be assessed on a case-by-
case basis and discussed with the referring physician and patient. The
key elements of the discussion should be included as part of the dictation.
Refer to the X-Ray Safetypolicy 13.70.002 for information
regarding administering ionizing radiation to a pregnant patient.
Breastfeeding – Breastfeeding patients are informed that a tiny amount of
the contrast is passed into the breast milk and absorbed by the baby,
though the amount is estimated to be less than 0.01% of the amount given
to the mother. The patient can choose to continue nursing her baby, or
express and discard her breast milk for 24 hours fol owing contrast
injection if she has any concerns about potential harm to the baby. The
patient should be given the information pamphlet
Myasthenia gravis – The risk of exacerbation of myasthenia gravis (MG)
with the administration of IV contrast is felt to be very low. Patients with
MG may receive IV contrast whenever IV contrast is clinical y indicated. If
there is any concern, the referring physician should be consulted.
Venous access – A radiologist is cal ed when venous access cannot be
obtained. If an inpatient with a central line has been accompanied by a
nurse, the nurse accesses the line for the technologist, the technologist
attaches the contrast line, injects, and removes the contrast line. The
nurse flushes and reattaches the original line. When injecting contrast
through a central line:
the injection flow rate must be limited to 3 mL per sec maximum contrast should be warmed to body temperature to reduce viscosity the line must be tested for patency using saline the connector labeled distal or large should be used since this route has no side holes (on the Arrow lines, this connector is brown) after contrast, the line must be flushed with saline to prevent occlusion staff should refer to applicable hospital policies for further information  UHN Vascular Access –policy 3.60.003 This material has been prepared solely for use at Mount Sinai Hospital (MSH), University Health Network (UHN) and Women’s College Hospital (WCH). MSH/UHN/WCH accept no responsibility for use of this material by any person or organization not associated with MSH/UHN/WCH. No part of this document may be reproduced in any form for publication without permission of MSH/UHN/WCH. A printed copy of this document may not reflect the current, electronic version on the MSH/UHN/WCH Intranet.
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Peripheral y inserted central catheters (PICC), implanted vascular access
devices (VADs) (e.g., Port-a-Caths®) and tunneled central VADs (e.g.,
Hickman® catheters) are not to be used for contrast injection, unless they
are specifically designed for high pressure injections (i.e. Power PICCs,
Power Ports).
Administration of Gadolinium-based Contrast Agents (GBCA) for CT
Rarely, at the discretion and under direct supervision of the radiologist, a GBCA is used as the IV contrast agent for CT. In this situation, refer to thepolicy 16.30.004.
Technologists are responsible for knowing the location of the nearest contrast reaction box and crash cart, and the phone extension to initiate a Code Blue. Technologists must be familiar with the contents of the contrast reaction box.
Procedure
Medical History & Explanation of Risk
On arrival, ask the patient to read theand to complete the medical history checklist.
• Give the patient a(form D-3362) information for patients sheet.
• Verbal y review the risks and history with each patient.
• If the patient’s history indicates that a possible contraindication exists as outlined under contact a radiologist for further instructions.
Prior to starting the procedure, question the patient again to confirm that no contraindications exist.
• Confirm that the patient understands the risks associated with injection of IV • Ask the patient if he/she has any questions.
• If there are any questions you are unable to answer, cal a radiologist to speak Obtain the patient’s verbal consent to continue.
This material has been prepared solely for use at Mount Sinai Hospital (MSH), University Health Network (UHN) and Women’s College Hospital (WCH). MSH/UHN/WCH accept no responsibility for use of this material by any person or organization not associated with MSH/UHN/WCH. No part of this document may be reproduced in any form for publication without permission of MSH/UHN/WCH. A printed copy of this document may not reflect the current, electronic version on the MSH/UHN/WCH Intranet.
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Document verbal consent, any contraindications, and radiologist involvement in the Radiology Information System (RIS).
After the procedure is complete, give al patients receiving IV contrast injections a contrast reaction card with instructions to fol ow in case of a delayed reaction.
Preparation of Power Injectors & Syringes with Contrast Media
• Draw up contrast media for IV injection into the injector at the time of the • Change the extension set containing 2 one-way check valves between each • Change the entire injection set-up between patients, or if multi-dosing is approved by the site’s Infection Prevention and Control Department, every 4 hours.
• Draw up contrast media for IV injection into a syringe at the time of the • Cap the syringe using a one-handed technique.
• Attach a label indicating the type and strength of solution, date and time of • Place the empty bottle of contrast by the syringe to verify its contents.
• After injection, dispose of the syringe into a biohazardous sharps container without recapping.
• Discard any syringes with contrast media that are not used within 4 hours of Note: Any syringes with solutions not drawn up by the technologist performing the
examination and lacking an appropriate label detailing contents and date/ time of preparation must be discarded.
Document al contrast injections in RIS. Include volume, lot number, and injection site.
This material has been prepared solely for use at Mount Sinai Hospital (MSH), University Health Network (UHN) and Women’s College Hospital (WCH). MSH/UHN/WCH accept no responsibility for use of this material by any person or organization not associated with MSH/UHN/WCH. No part of this document may be reproduced in any form for publication without permission of MSH/UHN/WCH. A printed copy of this document may not reflect the current, electronic version on the MSH/UHN/WCH Intranet.
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Where available, empty unused contrast into pharmaceutical waste bins before disposing of the container.
Management of Reactions to IV Contrast Media
For all reactions:
If there is a reaction, other than transient, self-limiting signs and symptoms such as a metal ic taste, warmth, tingling/coolness at the injection site, consult with a resident/fel ow/radiologist.
Assist the resident/fel ow/radiologist, as appropriate.
Document al observed or reported reactions, whether immediate or delayed, in RIS, in the patient’s chart (if an inpatient), and in the Hospital information system, in: • Electronic Patient Record (EPR) at UHN, including an al ergy alert • Cerner at MSH, including an al ergy alert Initiate a patient incident report and forward it to the charge technologist/modality supervisor, site manager, and covering radiologist.
For mild reactions: (e.g., rash, diaphoresis, pal or or flushing of the skin),
Prepares and administers medication, if ordered by the radiologist.
Advises the patient of the importance of informing Hospital personnel about the reaction before receiving further IV contrast media and provides the patient with ainformation sheet.
Assesses the condition of the patient.
This material has been prepared solely for use at Mount Sinai Hospital (MSH), University Health Network (UHN) and Women’s College Hospital (WCH). MSH/UHN/WCH accept no responsibility for use of this material by any person or organization not associated with MSH/UHN/WCH. No part of this document may be reproduced in any form for publication without permission of MSH/UHN/WCH. A printed copy of this document may not reflect the current, electronic version on the MSH/UHN/WCH Intranet.
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Completes the physician’s section of the incident report e-form.
For moderate reactions (e.g., light headedness, shortness of breath, tightness
and/or pain in the chest; may include wheezing, facial edema, laryngeal edema,
pronounced cutaneous reaction, rigors and/or cardiac arrhythmias),
Lays the patient down with feet elevated.
Takes blood pressure, pulse, and respiration as instructed by the radiologist.
Prepares and administers medication as ordered by the radiologist.
Sends the patient to the Emergency Department if instructed by the radiologist.
Advises the patient of the importance of informing Hospital personnel about the reaction before receiving further IV contrast media. Provides the patient with ainformation sheet and appropriate product monograph. Suggests that the patient wear an “alert” bracelet in case of an accident.
Assesses the condition of the patient.
Completes the physician’s report section of the incident report e-form.
For life-threatening reactions (e.g., unresponsiveness, cardiopulmonary arrest,
marked hypotension),
This material has been prepared solely for use at Mount Sinai Hospital (MSH), University Health Network (UHN) and Women’s College Hospital (WCH). MSH/UHN/WCH accept no responsibility for use of this material by any person or organization not associated with MSH/UHN/WCH. No part of this document may be reproduced in any form for publication without permission of MSH/UHN/WCH. A printed copy of this document may not reflect the current, electronic version on the MSH/UHN/WCH Intranet.
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If unable to arouse the patient, cal s for help.
Opens the airway, observes for breathing, and checks carotid pulse.
If the patient is not breathing and there is no carotid pulse, cal s an arrest and starts cardiac compressions.
Takes the patient to the Emergency Department if instructed by the radiologist.
Advises the patient of the importance of informing Hospital personnel about the reaction before receiving further IV contrast media. Provides the patient with ainformation sheet and appropriate product monograph. Suggests that the patient wear an “alert” bracelet in case of accident.
Assesses the condition of the patient.
Completes the physician’s section of the incident report e-form.
Management of Contrast Media Extravasation
Whenever contrast extravasation occurs, inform the resident/fel ow/radiologist.
• Complete an incident report and forward it to the charge technologist/modality supervisor, site manager, and covering radiologist.
The resident/fel ow/radiologist examines the patient and informs him/her of possible complications, and how to care for the affected area.
Apply a cold compress to the local site and elevate the extremity.
Observe the patient in the Department at the discretion of the physician.
When the patient’s condition al ows, discharge him/her home/to the unit with instructions to apply a cold compress for 15 to 20 minutes, 1 to 3 times/day.
This material has been prepared solely for use at Mount Sinai Hospital (MSH), University Health Network (UHN) and Women’s College Hospital (WCH). MSH/UHN/WCH accept no responsibility for use of this material by any person or organization not associated with MSH/UHN/WCH. No part of this document may be reproduced in any form for publication without permission of MSH/UHN/WCH. A printed copy of this document may not reflect the current, electronic version on the MSH/UHN/WCH Intranet.
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• If there are any signs of vascular compromise (cool limb, numbness in the limb, increased pain), keep the patient in the Department until seen by Plastic Surgery.
• Instruct the patient to seek medical help immediately at the nearest emergency department if any of these symptoms occur after returning home.
Document contrast extravasation and treatment in the RIS.
References
ARC Committee on Drugs and Contrast Media. Administration of Contrast Medium to Breastfeeding Mothers http://www.asklenore.info/breastfeeding/contrast_media.shtml American Col ege of Radiology Manual on Contrast Media, version 7, 2010 Bettmen, MA. Frequently asked questions: Iodinated contrast agents, RadioGraphics 2004; 24:S3-S10 Canadian Association of Radiologists: Guidelines for the prevention of contrast induced nephropathy. Available at www.car.ca.
Medical Staff Bul etin, Volume 37, No.22. Estimated GFR. University Health Network The Use of Central Venous Catheters for Intravenous Contrast Injection for CT Examinations, This material has been prepared solely for use at Mount Sinai Hospital (MSH), University Health Network (UHN) and Women’s College Hospital (WCH). MSH/UHN/WCH accept no responsibility for use of this material by any person or organization not associated with MSH/UHN/WCH. No part of this document may be reproduced in any form for publication without permission of MSH/UHN/WCH. A printed copy of this document may not reflect the current, electronic version on the MSH/UHN/WCH Intranet.
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Patient Care
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02/09; 10/10; 06/11
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Radiologist-in-Chief

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