Frimley Park Hospital Radiology Department IV Contrast Policy. August 2011

Transcription

1 Frimley Park Hospital Radiology Department IV Contrast Policy August 2011 FPH Radiology Contrast Policy August 2011

2 Contents Page IODINATED CONTRAST GUIDE 1 Guidance for the use of IV iodinated contrast- Introduction 2 Patients at increased risk of allergic reactions 3 Contrast Nephrotoxicity 5 Metformin 6 Special Cases 6 Pregnancy 6 Breast Feeding and Lactation 6 Thyroid 7 Interleukin-2Treatment 7 Recommendations for Outpatient observation following IV contrast 8 MRI CONTRAST GUIDANCE 9 APPENDICES 12 Instructions to the referrer Appendix A Renal Function and Contrast Policy Appendix B Hydration Regimes for patients requiring IV iodinated contrast Appendix C Metformin and IV Contrast Policy Appendix D Severe Renal Impairment and IV contrast Guidance Appendix E Ward Advice for inpatients receiving IV iodinated Contrast for CT Appendix F CT Injections Safety Questionnaire Appendix G Protocol for Radiographer Prescribing IV iodinated Contrast Appendix H Guidance for Emergency Department Doctors for Limited IVU Appendix I IVU Contrast injection Safety Questionnaire Appendix J Management of Contrast Reactions Appendix K Guidelines for treatment of extravasation of contrast media Appendix L Workflow for outpatient CT Appendix M Guidance for staff booking Contrast CT appointments Appendix N Guidance for Staff booking IVU outpatients Appendix O REFERENCES FPH Radiology Contrast Policy August 2011

3 IODINATED CONTRAST GUIDANCE FPH Radiology Contrast Policy August

4 GUIDANCE FOR THE USE OF IV IODINATED CONTRAST To minimise potential contrast reactions in patients, patients at increased risk of a reaction need to be identified. A patient safety questionnaire should be completed by the patient to enable the person prescribing the contrast to determine whether to proceed with IV iodinated contrast examination. The two main groups of patients to identify are those that are at increased risk of an allergic reaction and those at increased risk of contrast nephrotoxicity. There are other groups which require special consideration including those patients on metformin, pregnant patients, thyroid cancer patients, hyperthyroid patients and patients on interleukin-2 therapy. The CT patient questionnaire is also used as a second check to identify patients who have had recent investigations using ionising radiation at other centres. FPH Radiology Contrast Policy August

5 PATIENTS AT INCREASED RISK OF ALLERGIC REACTIONS In all cases where there is an increased risk of allergic reaction, be ready to treat any adverse reaction promptly. Previous contrast reactions Caution should be exercised when there is a previously reported moderately severe (bronchospasm or urticaria requiring treatment) or a severe reaction (for example laryngeal or angioneurotic oedema, severe bronchospasm or collapse). Skin reactions have been reported up to a week after the administration of contrast medium for which symptomatic treatment only is required. The status and significance of these delayed skin reactions are uncertain. Advice -determine the exact nature of the previous reaction and the agent used on that occasion. -re-examine the need for a contrast examination with respect to an unenhanced scan or alternative investigations. -Consider the risk-benefit ratio of the procedure. If the contrast is deemed necessary - use a different contrast agent if known - Maintain close medical supervision -Leave the cannula in place for 30 minutes after the procedure Multiple allergies or a documented severe allergy requiring therapy Individuals with multiple, well-documented allergies or a single very severe allergy are at increased risk. Advice -Determine the nature of allergies and their sensitivity (please note that there is no specific cross reactivity with shellfish or topical iodine in acute reactions i.e. these are not contra-indications to IV iodinated contrast) - Re-examine the need for contrast with respect to an unenhanced scan or alternative investigations. -The risk-benefit ratio of a contrast enhanced scan should be considered If the contrast scan is deemed necessary -Maintain close medical supervision -Leave the cannula in place for 30 minutes after the procedure. FPH Radiology Contrast Policy August

6 Asthma Asthmatics are at an increased risk of contrast reactions by a factor of six with low / iso-osmolar non-ionic contrast agents and by a factor of ten with high osmolar agents. Advice -Determine whether the patient has true asthma rather than COPD - Determine whether the asthma is currently well controlled If the asthma is well controlled and there are no other risk factors for allergic reactions, contrast can be administered -Maintain close medical supervision -Leave the cannula in place for 30 minutes after the procedure If the asthma is well controlled but there are other multiple risk factors for the patient being at an increased risk of contrast reaction, reexamine the need for a contrast examination with respect to an unenhanced study or alternative investigations. If a contrast examination is deemed necessary -Maintain close medical supervision -Leave the cannula in place for 30 minutes after the procedure. If the patient is wheezy or reports that their asthma is not currently well-controlled and the examination is not urgent, the patient should be deferred and referred back for appropriate medical therapy. FPH Radiology Contrast Policy August

7 CONTRAST NEPHROTOXICITY All intravascular iodinated contrast media (CT, IVU, and angiography) are potentially nephrotoxic. The risk of contrast induced nephropathy (CIN) is related to the extent of preexisting renal impairment, the dose of contrast agent and the state of hydration of the patient. The combination of renal impairment and diabetes mellitus carries increased risk. Other risk factors for CIN include congestive cardiac failure, old age (>70 years) and concurrent administration of nephrotoxic drugs. To identify patients with pre-existing renal impairment, a recent egfr should be made available in adults. In non-emergency patients who are stable, an egfr within the previous three months is satisfactory. If the patient has an acute illness or if there is known renal impairment, an egfr from the previous seven days should ideally be obtained. If there is no renal function available or if there is impaired renal function in the past three months but no repeat egfr in the preceding week, contrast administration should be discussed with the Radiologist overseeing the CT session. The Radiologist should determine whether the patient has increased risk factors for CIN and, using this information in combination with the indication for the scan, should decide whether to proceed with the scan (with or without contrast) or whether to rebook the scan at a later date with a renal function checked in the interim period (n.b. patients who have their scan postponed due to lack of availability of a recent egfr should be provided with a request form to have their renal function checked prior to leaving the department). The Renal Function and Contrast Policy (please see Appendix B) should be used as a guide for administering renal contrast with respect to renal function. All patients should be hydrated (please see Appendix C). Please note that there are special circumstances where the benefits of the use of iodinated contrast in patients with severe renal failure is deemed to outweigh the risks but there are strict guidelines for this (please see Appendix E). In children, unless the patient is acutely unwell or known to have renal impairment, a renal function is not required. FPH Radiology Contrast Policy August

8 METFORMIN Metformin is not recommended for use in diabetic patients with renal impairment as it is excreted exclusively via the kidneys. Accumulation of metformin may result in the development of lactic acidosis. The renal function should be known in patients who require IV iodinated contrast agents. If the renal function is normal, there is no need to stop the metformin. Metformin should be stopped if the renal function is abnormal, please refer to the Metformin protocol for specific instructions (Appendix D). SPECIAL CASES PREGNANCY Any CT request for a pregnant patient should be approved by a Consultant Radiologist. All CT body examinations (i.e. excluding CT Brain) should be requested by the Consultant Clinician. Please note: The Obstetrics & Gynaecology team (Registrar level or above) should be aware of all hospital attendances of all pregnant patients or patients who are within the 6 weeks postnatal period. In exceptional circumstances, contrast may be given during pregnancy. There is a small theoretical risk of thyroid suppression in the foetus and it is suggested the thyroid function should be measured in the first week after birth. This is performed routinely as part of post natal care. For any CT examination of the chest, the maternal radiation dose to the breasts should be considered. This is most likely to arise as part of investigations for pulmonary embolism. First line investigation for pulmonary embolism should be Doppler Ultrasound of both lower limbs and not CTPA. If the Doppler Ultrasound is negative, the decision to investigate with a CTPA or V/Q scan should be made in consultation with the patient. Pregnant patients undergoing CTPA should be made aware of the radiation dose to the breast. BREAST FEEDING AND LACTATION A small percentage of the injected dose enters the breast milk and virtually none is absorbed across the normal gut. No special precaution or cessation of breast feeding is required. For CT of the chest, the radiation dose to the breast should be considered and the examination should be requested by the Consultant Clinician. Investigations for pulmonary embolism should follow the same pathway as pregnant patients with respect to the breast radiation dose. FPH Radiology Contrast Policy August

9 THYROID In patients with known thyroid cancer or if the patient is being investigated for possible thyroid cancer, IV iodinated contrast should not be given; the use of IV iodinated contrast in these patients will prevent the patient from receiving therapeutic radio-iodine treatment for two months. Patients who are clinically hyperthyroid (untreated hyperthyroidism or uncontrolled hyperthyroidism) should also not receive IV iodinated contrast. INTERLEUKIN-2-TREATMENT There is a specific risk of a delayed skin rash associated with interleukin-2 therapy (oncology). Oncologists should indicate if the patient is on this drug when referring them for a contrast scan. Patients on interleukin-2 therapy should be warned that it is possible to have a delayed skin reaction and to consult their doctor if they have any problems. FPH Radiology Contrast Policy August

10 RECOMMENDATIONS FOR OUT-PATIENT OBSERVATION FOLLOWING IV IODINATED CONTRAST Following IV iodinated contrast, the patient should remain in the department for at least 15 minutes. In patients with an increased risk of an allergic reaction, this should be doubled to 30 minutes. The cannula should remain in-situ for this time period. Patients with an increased risk of a reaction: - Asthma - Multiple allergies or a severe allergy requiring treatment - Previous contrast reaction (Atopic disorders e.g. hayfever can be considered in conjunction with any other relevant history of allergies) Any contrast reaction should be recorded on RIS and should include the contrast agent used, the nature and severity of the reaction. FPH Radiology Contrast Policy August

11 MRI CONTRAST GUIDANCE FPH Radiology Contrast Policy August

12 MRI EXAMINATIONS REQUIRING CONTRAST There are a number of MRI examinations requiring IV contrast. The following are indications for contrast enhanced MRI:- MR Angiography Indirect arthrography Tumour staging Evaluation of lumps, masses, swellings Morton s neuroma Investigation for infective or inflammatory processes e.g.?osteomyelitis Gadolinium-containing contrast agents (MRI contrast agents) are associated with a varying degree of risk of nephrogenic systemic fibrosis (NSF) in patients with severe renal impairment. NSF is rare but is a serious and life-threatening condition characterised by the formation of connective tissue in the skin which becomes thickened and hard, sometimes leading to contractures and joint immobility. Systemic involvement of other organs can occur including the lungs, liver, muscles and heart. The MRI contrast agent we mainly use in our department is Dotarem which is categorised as a low-risk agent but in patients with an egfr<30 a Consultant Radiologist must authorise its use. Dotarem is currently not contraindicated in patients with CKD 4 & 5 but careful consideration is advised. Occasionally we use Primovist as the MRI contrast agent. It is a liver specific agent actively uptaken by hepatocytes. It is categorised as a medium risk agent. Administration of Primovist should be avoided in patients with CKD 4 & 5 unless the diagnostic information is not available by any other means. Alternative investigations should be considered in patients with severe renal impairment. The risk of inducing NSF must always be weighed against the risk of the patient not having an essential gadolinium enhanced scan; at-risk patients should not be denied clinically important contrast-enhanced MRI examinations. For all patient groups, a single lowest dose possible should be used and not repeated for 7 days. FPH Radiology Contrast Policy August

13 A recent renal function (within 2 months) is required for contrast enhanced MRI if:- - the patient is over 65 years old - the patient is diabetic - the patient is a known hypertensive - the patient is known to have kidney problems - if the patient is awaiting a kidney or liver transplant Patients on haemodialysis should have their dialysis after the scan on the same day as the contrast examination. If this is not possible they should have it as soon as possible after the scan. In either scenario, they should have an extra dialysis session the following day. There is no evidence to support the initiation of haemodialysis in patients not already undergoing haemodialysis. Other patient groups to be considered regarding the use of MRI contrast:- Breast feeding: The decision whether to continue or suspend breast feeding for 24 hours after the use of Dotarem or Primovist should be at your discretion in consultation with the mother. Pregnancy: The use of any gadolinium-containing contrast agent is not recommended unless absolutely necessary. Perioperative liver-transplantation: If it is necessary to give Dotarem or Primovist, a single lowest possible dose can be used and should not be repeated for at least 7 days. Children: Dotarem is not licensed for use in children under 2 years old. A single lowest dose possible should be used and should not be repeated for at least 7 days. FPH Radiology Contrast Policy August

14 APPENDICES FPH Radiology Contrast Policy August

15 Appendix A Instructions to the referrer for CT, angiography, IVU and MRI requests All intravascular iodinated contrast media (CT, IVU, and angiography) are potentially nephrotoxic. The risk of contrast induced nephropathy (CIN) is related to the extent of preexisting renal impairment, the dose of contrast agent and the state of hydration of the patient. The combination of renal impairment and diabetes mellitus carries increased risk. Other risk factors for CIN include congestive cardiac failure, old age and concurrent administration of nephrotoxic drugs. Gadolinium-containing contrast agents (MRI) are associated with a varying degree of risk of nephrogenic systemic fibrosis (NSF) in patients with severe renal impairment. NSF is rare but is a serious and life-threatening condition characterised by the formation of connective tissue in the skin which becomes thickened and hard, sometimes leading to contractures and joint immobility. Systemic involvement of other organs can occur including the lungs, liver, muscles and heart. To enable us to identify those patients at increased risk, all patients for Contrast enhanced CT, IVU and angiography and selected patients for Contrast enhanced MRI examinations(* please see overleaf) will require a recent renal function (egfr). The risk-benefit ratio of the examination can then be assessed, steps can be taken to minimise risk and alternative tests could be considered if appropriate. Please indicate if oncology patients are on interleukin-2 therapy as they may be at increased risk of a specific delayed skin reaction after receiving IV iodinated contrast. CT, IVU AND ANGIOGRAPHY OUT-PATIENTS At the time of writing the request form please perform the following:- Check that a renal function (egfr) from the previous 2 months is available. If renal function is normal, please write the value (and date) on the request form. If renal function is out of the reference range, please write the value (and date) on the request form and provide the patient with a blood test form to be performed the week before the radiology appointment. If there is no renal function from the previous two months, please provide the patient with a form to have the renal function checked that day or in the next few days. Please document this action on the radiology request form. Please note that omitting these details may result in an unenhanced study being performed or a delay in performing an enhanced study and your co-operation is appreciated. FPH Radiology Contrast Policy August

16 Appendix A CT, IVU AND ANGIOGRAPHY IN-PATIENTS A recent renal function (i.e. admission renal function) is required for all of the examinations documented above. In emergency situations where a laboratory result is not achievable in a timely manner for the clinical needs of the patient, a point-of-care serum creatinine can be obtained and this can be used to calculate the egfr using the following egfr web-based calculator: n.b. Please DO NOT use any other web-based calculator; the link above has been approved as the correct calculator to use for adults with our laboratory and point-of-care methods and other egfr calculators may not be correct for our methods. The link is available on the intranet home page under clinical guidelines. Please note: In African-Caribbean patients, the egfr from a laboratory result should be multiplied by 1.21 to obtain the true egrf. If the egfr laboratory result appears low in an African-Caribbean patient, a true egfr can be calculated by this method. This does not apply to the egfr calculated by the web-based calculator as this has already been taken into account. MRI There are a number of MRI examinations requiring IV contrast. The following are indications for contrast enhanced MRI:- MR Angiography Indirect arthrography Tumour staging Evaluation of lumps, masses, swellings Morton s neuroma Investigation for infective or inflammatory processes e.g.?osteomyelitis A recent renal function (within 2 months) is required for contrast enhanced MRI if:- - the patient is over 65 years old - the patient is diabetic - the patient is a known hypertensive - the patient is known to have kidney problems - if the patient is awaiting a kidney or liver transplant Please arrange for the renal function to be checked in this group of patients if there is no recent egfr available. FPH Radiology Contrast Policy August

17 Appendix B Renal Function and Contrast egfr = / > 60 Give Omnipaque egfr NEED TO KNOW IF ACUTE RENAL FAILURE OR CHRONIC RENAL FAILURE: look up previous renal function to see if this is longstanding or an acute episode of renal impairment. If chronic renal impairment, give Visipaque and hydrate as per general hydration advice. If acute renal impairment or if you are unsure, discuss with a radiologist whether to give contrast. egfr 30 Do not give contrast (except in specific cases which have been confirmed with the radiologist: this usually concerns ITU patients on haemofiltration, chronic renal failure patients on dialysis and specific vascular cases. Please see Protocol for the authorised use of contrast in patients with severe renal impairment). In emergency situations where a laboratory result is not achievable in a timely manner for the clinical needs of the patient, a point-of-care serum creatinine can be obtained and this can be used to calculate the egfr using the following egfr web-based calculator: n.b. Please DO NOT use any other web-based calculator; the link above has been approved as the correct calculator to use for adults with our laboratory and point-of-care methods and other egfr calculators may not be correct for our methods. The link is available on the intranet home page under clinical guidelines. Please note: In African-Caribbean patients, the egfr from a laboratory result should be multiplied by 1.21 to obtain the true egrf. If the egfr laboratory result appears low in an African-Caribbean patient, a true egfr can be calculated by this method. This does not apply to the egfr calculated by the web-based calculator as this has already been taken into account. FPH Radiology Contrast Policy August

18 Appendix C Hydration regimes for patients requiring IV iodinated contrast Patients with severe renal impairment (egfr<30) The use of IV iodinated contrast CT in this patient group to be authorised ONLY by a Consultant Radiologist/Authorised Clinicians (Consultant Vascular Surgeons, Consultant Nephrologists). Patients with egfr Patients with egfr< 20 (or if clinically unwell OR if the patient is unable to drink sufficiently in patients with egfr 20-30) -Patient to drink 1L fluids in the hour prior to the exam. -Perform the exam using Visipaque as the contrast agent. -Following the procedure, the patient should drink 100mls of fluid per hour for 4 hours. -Admit the patient at 9am -Prescribe 1L Normal Saline IV over 4hours prior to the exam -Perform the exam using Visipaque as the contrast agent. -After the scan the patient can be discharged from the ward with the instruction to drink 100 mls of fluid per hour for 4 hours if the patient is able to drink sufficiently. n.b. if the examination/treatment is conventional angiography, the patient care should follow the specific post-angiogram instructions (e.g. bed rest etc). If the patient is unable to drink sufficiently, 100mls Normal Saline IV per hour for 4 hours should be prescribed.-n.b. In patients with pre-existing fluid overloaded, the above regime may be contraindicated and clinical assessment of fluid management for optimising the patient should be made. All other patients Patients should keep hydrated for the examination and the following should be used as a guide: The patient should drink approximately 1 litre of fluid in the hour prior to the examination. If the patient is unable to tolerate oral fluids (in-patients), 1 Litre of Normal Saline IV over an 8 hour period (4 hours pre-exam and 4 hours post-exam) should be administered. For IVUs, the hydration regime should start after the exam. Please note that patients attending for an unenhanced scan do not need hydration. However, if an unexpected finding is noted at the time of the exam and requires a post-contrast scan, the patient can begin hydrating following the exam using the instructions above. Hydration advice should not delay emergency scans. FPH Radiology Contrast Policy August

19 Appendix D Metformin and IV Contrast Policy NORMAL RENAL FUNCTION (egfr>60 ml/min) do not stop metformin ABNORMAL RENAL FUNCTION (if the egfr is below 60 ml/min) OUTPATIENTS INPATIENTS 1) Stop taking metformin on the following days -the day before the exam -the day of the exam -the day after the exam 2) Advise the patient to be careful with their diet for the period of time that they are not taking metformin (regarding their diabetic control). 3) If the patient is concerned about the control of their diabetes, they should contact their diabetes team. 4) Keep hydrated. In the hour before the scan, approximately 1 litre of oral fluids should be consumed. 1) Stop the metformin for 48 hours (i.e. if the patient has already had their metformin earlier in the day, the next consecutive 48 hours doses should be omitted). 2) Careful dietary control of diabetes for the period of time that they are not taking metformin. 3) Monitor the patients blood glucose more frequently. 4) Clinical team to decide if any further diabetic control is required during the period of time that the patient is not on metformin. 5) Keep the patient hydrated. In the hour before the scan, approximately 1 litre of oral fluids should be consumed. If oral fluids are not possible, they should have 1 litre of Normal Saline IV over 8 hours (4 hours pre-exam and 4 hours post exam). -n.b. In patients with pre-existing fluid overloaded, the above regime may be contraindicated and clinical assessment of fluid management for optimising the patient should be made. FPH Radiology Contrast Policy August

20 Appendix E Guidance for the authorised use of IV Iodinated Contrast in patients with severe renal impairment In the majority of patients with severe renal impairment (egfr< 30 ml/min) the use of iodinated contrast (CT, IVU, and angiography) is contraindicated. However, there are exceptional circumstances where IV contrast may be used. This is predominantly for vascular studies where no other imaging method can be used and therefore the benefits are deemed to outweigh the risks. CT aorta - pre EVAR - post EVAR follow-up - emergency scan for?aaa rupture CTA renal arteries CTA carotids (in MRI incompatible patients) CTA peripheral vessels (in MRI incompatible patients) CTA mesenteric arteries (investigation of GI bleed/ ischaemia) In such circumstances the following should be applied:- 1) Direct referral will only be accepted from authorised clinicians: Consultant Vascular Surgeons and Consultant Nephrologists. Any other referrers should discuss the case with a Consultant Radiologist first. Out-patients with egfr<30 Vascular Surgical Referral (Mr Leopold, Mr Gerrard, Mr Chong) All forms should be forwarded to Dr Hatrick or Dr Taylor for discussion at the Vascular MDT. A decision will be made at the Vascular MDT whether the patient should undergo the CT study. This decision will be documented clearly on the request form to enable the examination to proceed. Nephrology Referrals (Dr Andrews) Radiographers to show request form to a Consultant Radiologist to approve. In-patients with egfr<30 Each case can be discussed with the Consultant Vascular Radiologist/ Surgeon. Radiographers to show request form to a Consultant Radiologist to approve. FPH Radiology Contrast Policy August

21 Appendix E 2) Specific pre-hydration regime (in the elective setting); Patients with egfr Patients with egfr< 20 (or if clinically unwell OR if the patient is unable to drink sufficiently in patients with egfr 20-30) -Patient to drink 1L fluids in the hour prior to the exam. -Perform the exam using Visipaque as the contrast agent. -Following the procedure, the patient should drink 100mls of fluid per hour for 4 hours. -Admit the patient at 9am -Prescribe 1L Normal Saline IV over 4hours prior to the exam -Perform the exam using Visipaque as the contrast agent. -After the scan the patient can be discharged from the ward with the instruction to drink 100 mls of fluid per hour for 4 hours if the patient is able to drink sufficiently. N.b. if the examination/treatment is conventional angiography, the patient care should follow the specific post-angiogram instructions (e.g. bed rest etc). If the patient is unable to drink sufficiently, 100mls Normal Saline IV per hour for 4 hours should be prescribed.-n.b. In patients with preexisting fluid overloaded, the above regime may be contraindicated and clinical assessment of fluid management for optimising the patient should be made. 3) If the patient is diabetic and on metformin, the metformin should be omitted (please refer to metformin advice for inpatients and outpatients). 4) Omit potentially nephrotoxic medication, except those that are absolutely necessary, on the day of the iodinated contrast examination. 5) The renal function should be checked by the referring team 5-7 days after the contrast examination. Haemofiltration There are situations where patients with known severe renal failure on ITU on haemofiltration may require a contrast enhanced examination (CT contrast) and contrast can be given to these patients. The timing of the scan in relation to the haemofiltration is irrelevant but the consultant of the referring team must confirm the examination is required. Haemodialysis A contrast enhanced CT scan should be timed with the patients haemodialysis. Ideally the patient should have the scan and then their dialysis the same day. If the dialysis cannot be performed the same day, it should be performed the next day i.e. elective exams requiring contrast should not be performed on Fridays or Saturdays. (Patients on continuous peritoneal dialysis can continue with their peritoneal dialysis as normal). FPH Radiology Contrast Policy August

22 Appendix F Ward Advice for inpatients receiving IV iodinated contrast for CT Inpatients with impaired renal function (egfr< 60 ml/min) -please omit potentially nephrotoxic medication, except those that are absolutely necessary, on the day of the iodinated contrast examination. Diabetic patients on Metformin NORMAL RENAL FUNCTION ( egfr =/>60 ml/min) There is no need to stop metformin. ABNORMAL RENAL FUNCTION (egfr <60 ml/min) 1) Stop the metformin for 48 hours (i.e. if the patient has already had their metformin earlier in the day, the next consecutive 48 hours doses should be omitted). 2) Careful dietary control of diabetes for the period of time that they are not taking metformin. 3) Monitor the patients blood glucose more frequently. 4) Clinical team to decide if any further diabetic control required during the period of time that the patient is not on metformin. 5) Keep the patient hydrated (see below). Hydration advice -Patients should keep hydrated for the examination and the following should be used as a guide: The patient should drink approximately 1 litre of fluid in the hour prior to the examination. If the patient is unable to tolerate oral fluids, 1 Litre of Normal Saline IV over an 8 hour period (4 hours pre-exam and 4 hours post-exam) should be administered. n.b. In patients with pre-existing fluid overloaded, the above regime may be contraindicated and clinical assessment of fluid management for optimising the patient should be made. Please note patients attending for an unenhanced scan do not need hydration (typically CT brain, CT for bony injury, CT KUB etc). However, if an unexpected finding is noted at the time of the exam and requires a post-contrast scan, the patient can begin hydrating following the exam using the instructions above. Hydration advice should not delay emergency scan. FPH Radiology Contrast Policy August

23 Appendix G CT Injection Safety Questionnaire Name Date of Birth... Hospital Number. Address Your CT examination may require you to have an injection of a contrast medium (dye) into a vein. Please answer the following questions. Please circle your answer and add further information in the space provided. Have you had a CT before and if so when? YES / NO : Do you have a follow up appointment? YES / NO Date of appointment: Are you allergic to anything? YES / NO If yes, to what are you allergic to? Have you had an injection of x-ray contrast (dye) before? Have you ever been told that you are allergic to iodine? YES / NO YES / NO If yes, did the injection cause you any problems? If yes, was this painted on the skin? YES / NO or was it after an injection? YES / NO Do you have asthma? YES / NO If yes, have you ever been hospitalised with asthma? YES / NO Do you suffer from hayfever? YES / NO Do you have diabetes? YES / NO If yes, do you take Metformin (Glucophage)? Do you have kidney problems? YES / NO Do you have heart problems? YES / NO Are you known to have a thyroid disorder? YES / NO If yes, what is the disorder (e.g. overactive, underactive, other). Women of childbearing age. Are you, or could you be pregnant? YES / NO Are you breast feeding? YES /NO Please sign below to confirm that we have your name spelt correctly and your correct date of birth. Many thanks. Patients signature.. Radiographer Use Only Has the patient had a CT in the Yes / No (if yes, discuss with Radiologist) last three months? Renal Function egfr: Creatinine: Urea: Date: Checking Radiographer Signature: Date: FPH Radiology Contrast Policy August

24 Appendix H Protocol for Radiographer Prescribing IV iodinated Contrast IV iodinated contrast should not be used in patients with known or suspected thyroid cancer. Patients who are hyperthyroid (uncontrolled or untreated) should not receive IV iodinated contrast. A Consultant Radiologist must authorise the scan if any of the following are true:- - If the patient is pregnant or breast-feeding (the latter refers to radiation dose) - If the patient has had a CT in the previous three months. In all other patients, the following flow-diagram can be used. Have any previous contrast reactions, allergies, history of asthma or hayfever been identified? NO YES Is the allergy to topical iodine only (painted on the skin)? NO YES Has asthma been identified? YES Is it currently well controlled? NO YES NO Is the patients renal function normal (egfr=/>60)? NO Has a previous contrast reaction OR have multiple allergies/ severe reactions OR a combination or allergies + asthma or hayfever been identified? NO YES Check if there are previous renal function tests available. Is the egfr>30 AND is the renal function stable i.e. chronic renal impairment? YES NO or No previous tests available YES CT Radiographer can administer Omnipaque IV CT Radiographer can administer Visipaque IV Discuss with a Radiologist and document the decision on RIS FPH Radiology Contrast Policy August

25 Appendix I Emergency Limited IVU for renal colic: Patients suitability for contrast The doctor administering contrast should confirm that the correct patient has been selected for the IVU examination. This is because the doctor who may be administering IV contrast may not be the same doctor who requested the examination. CHECK LIST FOR CONTRAST ADMINISTRATION Criteria to establish; ALLERGIES -Has the patient previously had IV contrast? - If so, did the injection cause any problems; if yes, an alternative investigation should be sought. -Has the patient ever been told that they are allergic to iodine? If yes, was this painted on the skin (there is no specific cross reactivity with topical iodine in acute reactions) or was it after an injection? -Is the patient allergic to anything? - If so, what are they allergic to and type and severity of reaction? In those with multiple or severe reaction, reconsider the need for IV contrast and consider alternative investigation. ASTHMA AND ATOPIA - Is the patient asthmatic (true asthma rather than COPD)? If yes, is it currently well controlled? If it is not currently well controlled, consider whether an alternative investigation is appropriate. - Does the patient suffer from hayfever (answer to be considered in conjunction with any other evidence of atopia)? RENAL FUNCTION -Renal function on the day of the examination is required before contrast administration (egfr). If the renal function is abnormal the following should apply: If the egfr is less than 30 do not give contrast. If the egfr is 30-60ml/min, the degree of renal impairment and whether it is acute or chronic should be evaluated to determine whether or not the patient is suitable for IV contrast or whether an alternative investigation should be considered. In the event of IV contrast being administered in patients with a degree of renal impairment, the patient should be kept well hydrated. -All patients should keep hydrated for the examination and the following should be used as a guide: The patient should drink approximately 1 litre of fluid in the hour after the examination. If the patient is unable to tolerate oral fluids (in-patients), 1 litre of Normal Saline IV over an 8 hour period (after the exam) should be administered. -n.b. In patients with pre-existing fluid FPH Radiology Contrast Policy August

26 Appendix I overloaded, the above regime may be contraindicated and clinical assessment of fluid management for optimising the patient should be made. DIABETES -Is the patient on metformin? If yes and the egfr is >/= 60ml/min there is no need to stop the metformin. If the egfr is below 60 ml/min the following should be applied: 1) Stop the metformin for 48 hours (i.e. if the patient has already had their metformin earlier in the day, the next consecutive 48 hours doses should be omitted). 2) Careful dietary control of diabetes for the period of time that they are not taking metformin. 3) If the patient is an in-patient, monitor the patients blood glucose more frequently. Clinical team to decide if any further diabetic control is required during the period of time that the patient is not on metformin. 4) Keep the patient hydrated after the IVU; please refer to the section on renal function for a guide on hydration. PREGNANCY -The investigation of potential renal colic in pregnant patients should be directed under the urologists. Alternatives to IVU should be considered in the first instance. A single shot IVU can be considered but only with the direct input from the Consultant Urologist and alternative investigation should be considered first. THYROID HISTORY -In patients with known thyroid cancer or if the patient is being investigated for possible thyroid cancer, IV iodinated contrast should not be given; the use of IV iodinated contrast in these patients will prevent the patient from receiving therapeutic radio-iodine treatment for two months. Patients who are clinically hyperthyroid (untreated hyperthyroidism or uncontrolled hyperthyroidism) should also not receive IV iodinated contrast. Assessment of patient suitability for contrast should be made by the doctor using these criteria. If it is deemed that the patient is not suitable for contrast, an alternative investigation should be considered. Alternative investigations should not be performed overnight unless there are exceptional circumstances which would need discussion with the radiologist. FPH Radiology Contrast Policy August

27 Appendix J IVU Contrast Injection Safety Questionnaire Name Date of Birth... Hospital Number. Address Your IVU examination will require you to have an injection of a contrast medium (dye) into a vein. Please answer the following questions. Please circle your answer and add further information in the space provided. Are you allergic to anything? YES / NO If yes, to what are you allergic to? Have you had an injection of x-ray contrast (dye) before? Have you ever been told that you are allergic to iodine? YES / NO YES / NO If yes, did the injection cause you any problems? If yes, was this painted on the skin? YES / NO or was it after an injection? YES / NO Do you have asthma? YES / NO If yes, have you ever been hospitalised with asthma? YES / NO Do you suffer from hayfever? YES / NO Do you have diabetes? YES / NO If yes, do you take Metformin (Glucophage)? Do you have kidney problems? YES / NO Do you have heart problems? YES / NO Are you known to have a thyroid disorder? YES / NO If yes, what is the disorder (e.g. overactive, underactive, other). Women of childbearing age. Are you, or could you be pregnant? YES / NO Please sign below to confirm that we have your name spelt correctly and your correct date of birth. Many thanks. Radiographer Use Only Patients signature.. Renal Function egfr: Creatinine: Urea: Date: Checking Radiographer Name: Signature: Date: Radiologist or Clinician confirming that patient is suitable for IV contrast Name: Signature: Date: FPH Radiology Contrast Policy August

28 Appendix K MANAGEMENT OF CONTRAST REACTIONS FPH Radiology Contrast Policy August

29 Appendix K Action by Radiographer or assistant Action by Radiologist Nausea / Vomiting Reassure patient. Provide vomit receiver and tissues. Stay with patient. Offer water to sip when patient feeling better Record on RIS Nausea / Vomiting Reassure patient. Provide vomit receiver and Administer anti-emetic drugs (severe / protracted) tissues. Stay with patient. Offer water to sip when patient feeling better Call Radiologist to review Record on RIS Urticaria (scattered - transient) Reassure patient. Red itchy raised areas of skin - can be Observation for 1 hour with cannula in situ round or cause rings. Known as Hives Call Radiologist to review. Assist Radiologist Record on RIS Urticaria (scattered - protracted) Reassure patient. Chlorphenamine maleate- 4mg PO or 10mg IM/ slow IV Observation for 1 hour with cannula in situ Drowsiness and / or hypotension may occur. Call Radiologist to review. Assist Radiologist Record on RIS Urticaria (Profound) As above Consider Adrenaline 1:1000, mls ( mg) intramuscularly Repeat as necessary. Contrast medium extravasation Elevate affected limb If symptoms do not resolve quickly, consider admit and monitor. Apply Kool pac to affected area If skin or soft tissues threatened consider surgical treatment (look for blistering or Follow extravasation policy signs of compartment syndrome- 5P's-pain, parasthesia, pallor, Discuss with Radiologist - consider review paralysis and pulselessness). Record on RIS Delayed skin reactions Skin reactions have been reported upto a week after administration of contrast medium. Symptomatic treatment only is required. The reaction should be recorded in the patient's RIS record. The status and significance of these reactions is uncertain FPH Radiology Contrast Policy August

30 Appendix K Reaction Action by Radiographer or assistant Action by Radiologist Bronchspasm EMERGENCY TREATMENT REQUIRED Salbutamol (2-3 deep inhalations) Chest tightness, wheezing, coughing Get Radiologist immediately. Adrenaline:Normal BP - 1:1000, mls ( mg) intramuscularly. Use shortness of breath. Like an asthma Oxygen by mask 6-10 litres / min smaller dose in a patient with coronary artery disease or in an elderly patient attack. Assist Radiologist Adrenaline: Decreased BP - 1:1000, 0.5ml (0.5mg) intramuscularly Laryngeal oedema EMERGENCY TREATMENT REQUIRED Adrenaline: 1:1000, 0.5ml (0.5mg) intramuscularly. Repeated as necessary Swelling of the throat. Throat feels like it Get Radiologist immediately. is closing up. Difficulty swallowing & breathing Oxygen by mask 6-10 litres / min Stridor - high pitched inspiratory noise Assist Radiologist caused by airway obstruction Call for emergency ambulance as for Crash Hypotension (Isolated) EMERGENCY TREATMENT REQUIRED IV fluids: rapidly Normal saline or Hartmann's solution Patient may feel faint. Low blood Call Radiologist to review immediately If unresponsive: Adrenaline: 1:1000, 0.5ml (0.5mg) intramuscularly. pressure - systolic less than 90mmHg. Elevate patient's legs Repeat as necessary Pulse may increase. Oxygen by mask 6-10 litres / min Hypotension - Vagal reaction EMERGENCY TREATMENT REQUIRED Atropine mg intravenously. Repeat if necessary after 3-5 mins to (Hypotension and bradycardia) Call Radiologist to review immediately 3mg in total (0.04mg / kg) Low blood pressure and slow heart rate Elevate patient's legs IV fluids: rapidly Normal saline or Hartmann's solution Oxygen by mask 6-10 litres / min Assist Radiologist Anaphylactoid reaction EMERGENCY TREATMENT REQUIRED Adrenaline: 1:1000, 0.5ml (0.5mg) intramuscularly. Repeat in 5mins if no clinical Sudden onset and rapid progression of Call Radiologist to review immediately improvement. symptoms. Life-threatening airway +/- Call reception for emergency ambulance Chlorphenamine 10mg IM/slow IV) Breathing +/or circulatory problems Suction airway if needed For all severe reactions and patients with asthma give Hydrocortisone with skin/mucosal changes Elevate legs if patient is hypotensive mg IM/slow IV) Urticaria, swelling (skin / throat), Oxygen by mask 6-10 litres / min If clinical manifestations of shock do not respond to drug treatment give 1-2 litres faintness, difficulty breathing, Assist Radiologist IV fluid. Rapid infusion or one repeat dose may be necessary. abdominal pain, vomiting, diarrhoea Inhaled salbutamol may be used an as adjunct if bronchospasm severe and does not respond rapidly to other treatments FPH Radiology Contrast Policy August

31 Appendix L GUIDELINES FOR TREATMENT OF EXTRAVASATION OF CONTRAST MEDIA. Extravasation of radiological contrast media occurs when the contrast is injected outside of the vein, or there is leakage of the contrast from the vein into the surrounding tissues. The patient may complain of pain, discomfort and swelling around the injection site. There may also be an increase in pressure during the injection when using a pressure injector. If extravasation occurs correct management will prevent further complications and will reduce patient discomfort. It will be difficult to say exactly how much contrast has extravasated, but the maximum amount can be determined. DIRECTIVE If a patient complains of pain during the injection and there is extravasation of contrast media the injection must be stopped, the injection site examined and the patient treated before undertaking the examination. PROTOCOL On suspicion of extravasation Stop the injection. Disconnect the syringe and recap the venflon or butterfly. Get the patient into a comfortable position to exam the injection site. If you are unsure if there is extravasation, ask a senior radiographer, a Registrar or a Radiologist for advice. Advise the patient of what has occurred. Ask the radiologist (or attending doctor) to review. With the cannula still insitu, an attempt to aspirate any of the extravasated contrast with the cannula can be made. If nil aspirated or when aspirated to dryness, remove the cannula. Remove needle or cannula and apply appropriate dressing. Apply light pressure to cannulation point to prevent bleeding. Apply a Kool Pac (wrapped in a pillow case) to the swollen area. Elevate limb FPH Radiology Contrast Policy August

32 Appendix L Encourage the patient to gently mobilise the affected limb. Ask radiologist (or attending doctor) to review to ensure no further treatment is required (skin blistering, parasthesia, altered tissue perfusion and increasing or persistent pain> 4hours suggest severe injury. If so, seek surgical advice- Plastic Surgeon). Give the patient the relevant advice sheet of aftercare following extravasation. After treatment the patient must be cannulated at another site before undertaking the examination. If the patient requires simple pain relief, please contact the x-ray nurses, the Radiology Registrar or the referring team for in-patients. If it is out of hours and there is no Radiology Registrar on site please escort the patient to be seen in A/E. Complete details of extravasation on RIS. If an in patient, contact the nurse in charge, the referring team and document the incident in the patient s notes, including the approximate amount of contrast that has extravasated. POLICY This policy is designed to ensure correct management of radiological contrast extravasation, minimise patient discomfort and prevent further complications to the area affected. FPH Radiology Contrast Policy August

33 Appendix L ADVICE TO PATIENTS FOLLOWING EXTRAVASATION OF CONTRAST MEDIA. OUT PATIENT Occasionally during an injection of a radiological contrast media (x-ray dye) the contrast does not flow into the vein but is inadvertently injected into the soft tissues surrounding the vein. This is called extravasation, and may cause some discomfort and swelling at the site of the injection. This is unfortunately what has happened to you today. Following this event, the Radiographer looking after you will: Remove the cannula and dress the injection site. Apply a Kool Pac to the swollen area. Advise you to elevate the limb and occasionally to gently move the arm. Following initial first aid treatment you will be allowed home. On arriving home, please follow this advice Regularly apply a cold pack (e.g frozen peas wrapped in a tea towel) for approximately half an hour to help reduce the swelling and discomfort. Do not apply the cold pack directly onto your skin. Elevate your arm on a pillow or cushion so that you are comfortable. Gently move your arm to encourage reduction of the swelling. If you feel that you require pain relief please take what you would normally take for pain or refer to your GP for advice. If the area appears to: change colour or if there is any blistering become more painful or you are unable to feel or move your hand or if you are concerned about the swollen area for any reason, please come to the Accident and Emergency Department. Please take this advice sheet with you. FPH Radiology Contrast Policy August

34 Appendix L ADVICE TO PATIENTS FOLLOWING EXTRAVASATION OF CONTRAST MEDIA. IN PATIENT Occasionally during an injection of a radiological contrast media (x-ray dye) the contrast does not flow into the vein but is inadvertently injected into the soft tissues surrounding the vein. This is called extravasation, and may cause some discomfort and swelling at the site of the injection. This is unfortunately what has happened to you today. Following this event, the Radiographer looking after you will: Remove the cannula and dress the injection site. Apply a Kool Pac to the swollen area. Advise you to elevate the limb and occasionally to gently move the arm. Following initial first aid treatment: The nurse looking after you will be informed and given advice for your treatment. Regular cold packs will be applied to the affected area. Your arm should be elevated but you should also mobilise it to help reduce the swelling. One of the doctors looking you will have been informed and asked to check the injection site. Details of the extravasation and advice for aftercare will be written in your notes. You will be returned to the ward. If you require pain relief, please speak to the nurse or doctor looking after you. If the area appears to: change colour or if there is any blistering become more painful or you are unable to feel or move your hand or if you are concerned about the area for any reason, please ask your nurse or doctor to examine the area. FPH Radiology Contrast Policy August