New guidance from the Royal College of Radiologists Standards for Intravascular Contrast administration to adult patients 9, 11, 12

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1 Admiistratio of Itraveous (IV) Iodiated Cotrast Media (CM) i the Radiology Departmet Type: Cliical Guidelies Register No: Status: Public Developed i respose to: Cotributes to CQC Core Stadard umber: New guidace from the Royal College of Radiologists Stadards for Itravascular Cotrast admiistratio to adult patiets 9, 11, 12 Cosulted With Post/Committee/Group Date Stuart Craig CT Lead Radiographer May 2016 Peg Lee Cosultat Radiologist/Former CT Lead Feb 2016 Radiologist Skadadas Gaeshaligham Cosultat Radiologist/CT Lead Radiologist March 2016 Adrea Fracis Radiology Goverace Lead October 2016 Hele Ellis Seior Pharmacist / Pharmacy Maager October 2016 Dora Bergma Specialist Midwife for Ifat Feedig October 2016 Professioally Approved By Skadadas Gaeshaligam Cosultat Radiologist/CT Lead Radiologist. May 2016 Versio Number 1.0 Issuig Directorate Radiology Ratified by: DRAG Chairmas Actio Ratified o: 24 th November 2016 Trust Executive Board Date December 2016 Implemetatio Date 25 th November 2016 Next Review Date October 2019 Author/Cotact for Iformatio Sam Edward Pery (Seior Radiographer) Policy to be followed by (target staff) All Doctors(Referrers), traied ad recogised o-medical referrers, Radiographers, Radiologists, Prescribers ad Staff ivolved with the Itra-Veous (IV) admiistratio of Cotrast Media (CM) Distributio Method , Itraet & Website Related Trust Policies (to be read i cojuctio with) PICC Mid Service Lie Maagemet Stadard Ifectio Prevetio Had Hygiee Safe Hadlig & Disposal of Sharps Dispose of Waste Products MRI Cotrast Admiistratio Policy Metal Capacity Act (2005) Policy Documet Review History Versio No Authored/Reviewed by Active Date 1.0 S. E. Pery, Seior Radiographer 25 th November

2 Idex 1.0 Purpose 2.0 Equality ad diversity 3.0 Ifectio Prevetio & Cotrol 4.0 Aims 5.0 Traiig 5.1 Certificatio ad accreditatio 5.2 Basic Life Support (BLS) traiig 6.0 Scope 6.1 Target audiece 6.2 Seekig advice 6.3 Whe cotrast should be admiistered 6.4 Presece of a radiologist or doctor 6.5 PGD 6.6 Adherece 7.0 Equipmet 7.1 Emergecy equipmet (crash trolley) 7.2 Drug tray 7.3 Other emergecy equipmet 7.4 Caulatio tray 7.5 Warmig cabiet 7.6 Power ijectio. 8.0 Prescribig Cotrast Media (I & out of hours) 9.0 Request forms 9.1 Demographics ad cotact iformatio. 9.2 Cliical details that should be preset Immediate pre-checks 10.1 Patiet idetificatio 10.2 Checkig whether cotrast is required 10.3 Explaiig the examiatio ad the reaso for IV Ijectio 10.4 Coset + Metal Capacity Act (MCA) 10.5 Pregacy check [also see sec 13.9] 10.6 Outstadig Nuclear Medicie (NM) tests 11.0 Patiet questioaire [also see Appedix 2] 12.0 CM checks i the departmet - idetifyig risk groups 12.1 Hyperthyroidism 12.2 Thyroid cacer ad radioiodie treatmet 12.3 Other essetial checks 12.4 Iter-luki-2-treatmet 12.5 Presece of shellfish or topical iodie reactio 12.6 Multiple allergies or sigle severe allergy 12.7 Presece of risk factors 12.8 Breastfeedig 12.9 Pregat females Referrig to patiet questioaire [also see Appedix 2] 13.0 Blood tests & Real fuctio - EGR ad limits 14.0 Whe bloods are ot available 15.0 Metformi Advice 16.0 Other importat cosideratios before caulatio 16.1 Fistula 16.2 Axillary Node Clearace (Mastectomy) 2

3 16.3 PICC Lies [also see Appedix 3] 16.4 Cetral Lies /Whe peripheral caulatio is impossible or cotraidicated 16.5 Difficulties with caulatio 16.6 If the patiet caot have cotrast or refuses cotrast Cotrast volumes 18.0 Additioal steps for reducig risk (whe cotrast is deemed ecessary) Caulatio 19.1 Veflo - why it is used 19.2 More tha 2 members of staff 19.3 Itroductio 19.4 Selectig vei 19.5 Cleaig ski Sai-Cloth CHG 2% or Steret? 19.6 Itroduce veflo 19.7 Whe to seek seior advice 19.8 Flushig veflo with salie Ijectig cotrast Moitor for potetial reactio Discoectig Sterile precautios 20.0 Maagemet of Cotrast Reactios. [see Appedix 7] 21.0 Extravasatios[See Appedix 6] 22.0 Waitig times after admiistratio of CM 23.0 Post Procedure Removig veflo 23.2 Advice to patiet 23.3 Recordig iformatio o CRIS 23.4 Recordig Cotrast Reactios & Alarms 23.5 MHRA Yellow Card Scheme reportig & Datix 23.6 Usig labels from cotrast Vials 24.0 Audit ad Moitorig 24.1 Reportig o-compliace 24.2 Auditig practice 24.3 Datix 24.4 Addressig compliace 25.0 Refereces Appedices 1 Cetral lies flow chart 2 Patiet Questioaire 3 PICC lies 4 Markig tool (CRIS) 5 Yellow card MHRA 6 Extravasatio Policy 7 Maagemet of Cotrast Reactios 8 Breastfeedig 9 Extravasatio advice leaflet 10 PICC lie testig with the Covidie Cotrast Ijector Pump 11 A table to summarise breast feedig guidace for commoly used CM 12 A look-up table to show volumes for portal veous imagig 13 A look-up table to show fixed volumes for listed examiatios 14 Camp Bastio cotrast wheel calculator 3

4 1.0 Purpose To provide a writte procedure for staff udertakig Itraveous (IV) Ijectio. To idetify the risk groups associated with IV iodiated Cotrast Media (CM) ad to outlie steps of reducig risk. To keep the umber of iodiated CM reactios as low as practically possible. Steps have bee made to esure this policy complies with the atioal Royal College of Radiologists (RCR) ad the Society ad College of Radiographers (SCoR). 2.0 Equality ad Diversity Mid Essex Hospitals is committed to the provisio of a service that is fair, accessible ad meets the eeds of all idividuals. 3.0 Ifectio Prevetio & Cotrol 4.0 Aims All staff should follow trust guidelies o ifectio prevetio ad cotrol. It is particularly importat to esure hads are decotamiated before ad after cotact with each patiet. To esure a high-quality service is provided to the ed service user To improve patiet safety To reduce the umber of associated adverse reactios To reduce the umber of extravasatios To reduce the risk of ifectio To prevet delays 5.0 Traiig 5.1 All Radiographers who perform IV caulatio must have completed a "Certificate of Competece i Admiisterig Itraveous Ijectios". This form of uiversity based qualificatio must be awarded by a istitutio that has bee accredited by the College of Radiographers (CoR). I house legacy traiig will be recogised. 5.2 Durig the traiig, the Radiographer must evidece a miimum umber of ijectios (1) icludig: Five (assisted/demostrated) ijectios Te (supervised miimum assistace) ijectios Twety supervised (o assistace) ijectios 5.3 The Radiographer must have atteded Basic Life Support (BLS) traiig. This local, madatory traiig course also requires attedig a refresher programme every two years as per trust policy. 4

5 6.0 Scope ad Resposibilities 6.1 The target audiece for this policy icludes the radiographers ad radiologists as justifiers of the examiatios ad admiistrators of IV cotrast. This guidace should also be used by cliicias who refer patiets for examiatios ivolvig IV cotrast. 6.2 Whe required, advice should always be take from a Radiologist. 6.3 Cotrast should oly be admiistered whe cliically idicated [Refer to ] 6.4 A idividual traied i recogisig ad treatig cotrast reactios should be immediately available i the departmet where cotrast is admiistered ad must be cotactable. I hours this is expected to be the duty radiologist (uless otherwise agreed).a IV examiatio should oly occur out of hours, if a doctor is preset. 6.5 Radiographers should ot proceed with IV caulatio whe patiets are uder the age of 18 or must they iject itraveous cotrast. The Patiet Group Directive (PGD) strictly excludes radiographers admiistratig IV cotrast i these cases. I these circumstaces the radiologist or doctor should be resposible for IV access ad cotrast admiistratio whe required. 6.6 All healthcare ad medical professioals have a resposibility to adhere to the priciples described i this policy/guidelie. 7.0 Equipmet The followig equipmet must be checked each morig before a patiet eters the room: 7.1 Emergecy equipmet (Crash Trolley) This should be the first port of call for reactios that eed maagig immediately ad for ay reactios that are moderate to severe i severity This trolley must be readily available whe required for fast retrieval. [Crash Trolley i CT01 Prep room] ad [Crash Trolley i CT02 Prep room]. This cotais: Epiephrie (Adrealie) Epiephrie (Adrealie) Amiodaroe Atriopie Sulfate Calcium Chloride Magesium Sulfate Sodium bicarboate Glucose 1 i 1,000 (1ml) marked FOR ANAPHYLAXIS (Box) PFS 1:10,000 i 10ml PFS 30mg/ml i 10ml PFS 3mg i 10ml PFS 10% w/v i 10ml 50% (1g i 2ml) 8.4% (10mmol i 10ml) 20% 500ml 5

6 7.2 Drug Tray This must be readily available. [Located i locked CT01 storeroom - i labelled cupboard] This cotais: Salie NaCl 09% 5ml Water for ijectios (2ml ad 10ml) Hydrocortisoe as sodium succiate (Solu-Corfef 100mg) Chloropheiramie (Pirito) 4mg tablets (Oral admiistratio) Epiephrie (Adrealie) (1:1,000 stregth) Itra-muscular oly (3) Selectio of eedles 2ml + 10ml syrige 7.3 Other emergecy equipmet The followig equipmet should also be available i the viciity Portable/Piped oxyge Suctio IV Trolley Crash Trolley - icludig mask, tubig ad scissors. - with suctio tubig ad a sterile yakeuer pre attached) - with a selectio of syriges, eedles, gloves, swabs - all cotets must be checked weekly ad the crash trolley seal should be checked o a daily basis as per trust protocol. 7.4 Caulatio equipmet (caulatio tray) 19g (Blue) /21g (Pik) Veflo / Caula Touriquet, Tape, Gauze Swab Steret (For short term caula placemet/out-patiets Sai-cloth CHG 2% wipe + IV dressig (For log-term caula placemet/i-patiets) Salie ( 5mls for flushig) Syrige (10ml) Drawig up eedle 7.5 Caulatio equipmet (cotrast warmig cabiet) Warmed o-ioic cotrast to body temperature ( C) 7.6 Power Ijector Pump This must be fully fuctioal ad i a serviceable coditio. Power ijectors are routiely serviced o a yearly basis. 8.0 Prescribig CM 8.1 The requiremet of cotrast must be made clear, after the request has bee justified by a radiologist or by a vettig radiographer (followig a writte protocol agreed by the radiologists). This will be siged ad will be made explicit either i the form of a protocol umber or by writig o the request. 6

7 8.2 For a radiographer to admiister CM, the Patiet Group Directive (PGD) must be followed. It is importat to ote the exclusios of the PGD. 8.3 Whe the PGD caot be followed it must be prescribed by a medical doctor. I hours, this will be the radiologist. Followig RCR guidace, there must be a writte record by the radiologist, siged ad dated o the request form (3) (2). This request ca the be scaed o CRIS. 8.4 Out of hours, the resposibility lies with the CM referrig cliicia/cliicia escortig the patiet to prescribe ad admiister IV cotrast. I all cases the doctor should follow advice ad istructio from the out of hours radiologist (Nighthawk/Medica) whe the call is iitially made for the sca to be accepted. 8.5 If the admiistratio of cotrast eeds to be repeated please cosult with the supervisig radiologist ad refer to the maufacture guidelies to prevet overdose. Repeatig admiistratio of cotrast ca also icrease the risk of acute kidey ijury (2) 9.0 Request forms 9.1 Request forms must iclude all of the patiets demographic iformatio plus the bleep umber of the referrer. This poit of cotact is particularly importat if the refer is eeded i a emergecy, or if they are required to admiister IV cotrast out of hours. It is also useful i situatios where the request eeds to be discussed. 9.2 The referrer must provide sufficiet cliical details i order to justify the CT sca. The referrer should also highlight whether a patiet has poor real fuctio, hyperthyroidism or history of a previous CM reactio o the request, as these factors could prevet CM admiistratio ad i some circumstaces could stop the CT sca from goig ahead. Further to this, Ocologists should idicate if a patiet is takig the Iterleuki-2 drug (2) (Also kow as Aldesleuki or IL-2) [See 13.4] Immediate Pre Checks 10.1 Three forms of ID must be checked i additio to the cliical details by the ijectig radiographer The requiremet of IV Cotrast must be checked [Refer to 9.0] by the radiographer prior to admiisterig the cotrast The radiographer is resposible for explaiig the examiatio to the patiet icludig the reaso for itraveous ijectio To proceed, the patiet must give coset (3). The idividual admiisterig the cotrast must esure that the patiet uderstads that it is to be give ad the patiet must agree to the procedure (2). If the patiet is ot able to cogitively make a decisio a MCA2 form must be i place [as per trust protocol] The radiographer must also check for risk of pregacy i females of child bearig age [Followig local protocol] 7

8 10.6 Nuclear Medicie (NM) isotope thyroid imagig scas should be avoided for two moths after IV admiistratio of CM (3) (2). It is therefore advised that CRIS is checked for ay outstadig NM scas prior to their CM sca. If the patiet has a outstadig scheduled NM sca the the decisio to give IV CM should be made by the referrig cliicia Patiet Questioaire See Appedix 2 for a copy of the patiet questioaire. This should be used for both outpatiets ad ipatiets. Patiet questioaires should be take o arrival CM checks i the departmet Idetifyig risk groups 12.1 Is the patiet hyperthyroid? Cotrast should NOT be admiistered as there is risk of thyroid storm which ca be life-threateig (2) Does the patiet have thyroid cacer? Use of cotrast will preclude therapeutic radio-iodie treatmet for 2 moths. MRI is the preferred stagig method for these patiets (2) The followig risk factors must also be checked i the departmet prior to Ijectio to highlight those at icreased risk ad therefore miimise the risk of adverse evets. This essetial iformatio icludes: - Previous cotrast reactio sesitivity to iodie-based CM - Asthma (If yes, is it well cotrolled?) - Real problems - Diabetes mellitus - Metformi therapy 12.4 Is the patiet o Iterleuki-2-treatmet? If yes, the patiet is at risk of a delayed ski rash. Seek radiologist advice. Also refer to [Sectio 19]. The referrer should always idicate if the patiet is o this drug whe referrig them for a cotrast ijectio Shellfish or topical iodie reactio? There is o specific cross reactivity however please see below [13.6] 12.6 Does the patiet have multiple well-documeted allergies? (or) a sigle severe allergy? If yes, the patiet is at a higher risk of reactio 12.7 I the presece of ay of the risk factors [Above] the decisio about CM admiistratio should be take oly by the radiologist supervisig the procedure I cases where there is history of a moderately severe or severe reactio, other potetial methods of ivestigatio or u-ehaced study should be cosidered 8

9 [also see sectio 19.0] Breastfeedig The RCR state that o special precautios or cessatio of breast feedig is required. Despite this, maufacture guidelies should be followed as the occasioal maufacture may recommed discotiuig breastfeedig for a brief period of time. I such circumstaces, a cotrast media that ca allow the cotiuatio of breast feedig should be used. See [Appedix 11] for a table of the most commo types of cotrast used at MEHT ad the associated breast feedig guidace Pregat females If the sca is justified by the radiologist to go ahead ad if admiisterig IV is ecessary, thyroid fuctio should be measured i the first week after birth due to the small theoretical risk of thyroid suppressio i the fetus Referece should also be made to the patiet questioaire [Appedix 2] ad advice from a radiologist should be sought if there are ay cocers or if the patiet has aswered yes to ay of the questios Blood tests/real fuctio 13.1 Patiets with poor real fuctio should be discussed with the duty radiologist prior to referral to the departmet 13.2 Estimated Glomerular Filtratio Rate (egfr) egfr is the preferred way of determiig kidey fuctio tha serum creatiie aloe ad should always be sought where possible Real bloods should be: - withi 3 moths (if pt i a stable coditio) - withi 7 days (if pt has acute illess or kow real disease) 13.4 Patiets receivig iodiated cotrast media who have a egfr below 40 ml/mi/1.73 m 2 are cosidered to be at risk of acute kidey ijury (2) 13.5 ABOVE >/= 40 ml/mi/1.73 m 2 = IV CM ca be admiistered (after pre-checks ad departmetal checks have bee cleared) BETWEEN = ml/mi/1.73 m 2 = IV CM ca oly be admiistered (after pre-checks ad departmetal checks have bee cleared) AND After cotact with the referrig team has bee made. The referrer must take o ay added resposibility/must weigh up the extra risk Vs beefit of IV CM ad 9

10 must give approval to proceed. Where possible commuicatio from referrig team should be writte ad must be documeted. Read sectio 19 (reducig risk). BELOW </= 34 ml/mi/1.73 m 2 = IV CM ot routiely recommeded. Seek radiologist guidace If dialysis has bee orgaised by the referrer, it must be performed withi 24 hours to reduce the risk of kidey ijury Whe bloods are ot available 14.1 It is advised that the referrer is made aware of situatio. It is the dow to their discretio as it is their resposibility to maage patiet further alog lie This also applies i emergecy situatios where blood tests may ot be readily available 15.0 Metformi Advice 15.1 There is o eed to stop metformi after cotrast i patiets with serum creatiie (3)p10. (2) withi the ormal referece rage ad/or egfr >60 ml/mi (NB: This is differet to the cut off limits for IV CM i sectio 13.5) If egfr is below 60, ay decisio to stop it for 48 hours should be made i (3)p10. (2). cosultatio with the referrig cliic 16.0 Other importat cosideratios before caulatio 16.1 Caulae should ever be sited withi a fistula for the admiistratio of IV Cotrast. Patiets o dialysis (i particular haemodialysis) are more likely to have a fistula (surgically modified blood vessel) withi their arm to aid blood trasfer (4) 16.2 Caulatio away from the side of a axillary ode clearace is recommeded (also referred to as lymph ode clearace, lymph ode dissectio or lymph ode removal) as complicatios ca be more severe if a extravasatio was to occur (5). Lymph ode removal is ofte associated with a Hx of mastectomy Caulatio ca sometimes be avoided if the patiet presets with a trust recogised CT safe, PICC Lie [See Appedix 3] 16.4 Is peripheral caulatio impossible or cotraidicated? I exceptioal circumstaces, CVP lies/cetral lies ca be used. Followig the flow chart protocol [Appedix 1] is recommeded. NB: a Sodium Chloride 0.9% flush should be carried out after IV cotrast admiistratio Does the patiet experiece difficulties with caulatio? A arm warmer ca sometimes help with caulatio by prevetig vasocostrictio. A alarm o CRIS ca help draw this to attetio of the team ext time to prevet delays. 10

11 16.6 If the patiet caot have cotrast or refuses it It must be documeted i the commets sectio of the examiatio page o CRIS. The case should be discussed with the duty radiologist before proceedig with the sca Cotrast Volumes 17.1 Adults ( 18 years of age) For scas that iclude portal veous abdomial imagig, referece to the volume look-up table should be made [Appedix 12].This will esure that cotrast is admiistered to the patiets weight thus adherig to the RCR guidelies of best practice. Other examiatios may require fixed volumes [Appedix 13] For trauma imagig, it is recommeded that the Camp Bastio cotrast calculator wheel is followed [Appedix 14] Childre & Youg Adults (< 18 years of age) Admiisterig 2ml/per 1kg of IV cotrast is recommeded for scas that iclude portal veous abdomial imagig. This volume calculatio is also recommeded for trauma imagig whe the patiet is </=9kg i weight For trauma imagig, it is recommeded that the Camp Bastio cotrast calculator wheel is followed whe the patiet is >/=10kg i weight [Appedix 14] For further advice o cotrast ad other ulisted examiatios please cotact a radiologist/ refer to the maufacture guidelies Cotrast volume must be prescribed by a radiologist (as patiets uder the age of 18 fall outside the PGD iclusio criteria) Some CM maufactures (such as Optiray) do ot recommed admiisterig to childre. I these cases, please use a alterative CM such as Visipaque. Always refer to maufacture guidace or a radiologist for advice if required Other steps for reducig risk If CM is deemed ecessary the followig steps ca be also take to reduce risk. Reduce the amout of CM for patiets at high risk Maitai close medical supervisio Be ready to treat ay adverse reactio promptly Esure the patiet is well hydrated prior to ad post sca Leave the caula i place for loger [For timigs see sectio 23.0] Use a o-ioic low osmolar CM 11

12 (i.e. Optiray or Niopam) or a iso-osmolar (3) CM (Visipaque) Always esure emergecy drugs ad equipmet are available ) [See Sectio 8] 19.0 Caulatio 19.1 The veflo is the most preferable type of caula for itraveous cotrast. It is advatageous as it ca stay i ad ca be used for emergecy access if a cotrast reactio was to occur The ijectig radiographer plus oe member of staff should always be preset. They must both check the dose, expiry date ad type of cotrast to be ijected Explai procedure to patiet ad itroduce yourself by ame ad professioal title. Wash your hads Select a appropriate vei by use of a touriquet 19.5 For short-term caula placemet/ out-patiets ski should be cleaed with a steret (isopropyl) [trust protocol] 19.6 For log-term caula placemet/ i-patiets ski should be cleaed with a Sai-Cloth CHG 2% wipe [trust protocol] 19.7 Itroduce veflo ito vei ad secure with tape (or IV dressig particularly for logterm ad/or i-patiet use) Seior advice should be summoed if there has bee two failed attempts at securig itraveous access 19.9 Fill a 5ml/10ml syrige with sodium chloride (NaCl) ad expel ay air. Coect the salie filled syrige to the veflo ad flush. Esure there is o pai o flushig ad check there is o extravasatio. The salie should flow with ease Iject cotrast ad observe the ijectio site of the patiet for ay leakage If ay adverse reactio occurs stop ijectig ad seek advice DO NOT remove the veflo. Commece maagemet of adverse reactios to CM. [Appedix 7] Discoect cotrast tubig from caula ad secure with a bug Note that the procedure should observe sterile precautios 20.0 Maagemet of Cotrast Reactios 20.1 For immediate maagemet [See Appedix 7] for RCR guidace After the reactio has bee documeted [Sectio ] sigificat suspected cotrast reactios should be ivestigated appropriately with advice give to the patiet. For elective patiets, a referral made to a specialist drug allergy service is also advised to help guide future maagemet (2). 12

13 21.0 Extravasatios [Refer to Appedix 6 for Full Guidace] Immediately stop ijectio Elevate the affected limb (3) Apply ice packs to the affected area for a cold compress [Foud i CT02 refrigerator] (3) Iform radiologist/doctor supervisig ijectio It is the radiologist s resposibility for the patiets maagemet ad follow up The extravasatio policy must be followed i full [located i: Appedix 6]. Prit out the patiet advice leaflet [located i: Appedix 9] Waitig times after the admiistratio of CM 22.1 The patiet should ot be left aloe or usupervised i the first five miutes after the (3) (2). ijectio 22.2 The patiet should remai o the premises for at least 15 miutes post ijectio For patiets with a icreased risk they should remai o the premises for at least 30 miutes Patiets should be advised ot to drive for oe hour followig the admiistratio of CM 23.0 Post Procedure 23.1 Whe removig the veflo, the eedle must be safely disposed of i the sharps bi. A swab should the be placed o the ijectio site ad pressure should be applied. Pressure should be applied for loger for those patiets who are takig aticoagulats icludig Aspri ad Warfari. Whe bleedig has stopped, a dressig should the be used to cover the pucture site The followig advice should be give to the patiet/carer. This iformatio is also available o the departmetal PGD Patiets may drik ad eat ormally (uless specifically told ot to) Cotiue with ay prescribed medicatio (uless specifically told ot to) The patiet should iform a staff member if they experiece a warm or cold feelig at the ijectio site, ausea/vomitig, headache, shortess of breath or a rash Outpatiets ad GP patiets should be advised to cotact their GP or NHS Direct if they experiece ay delayed problems 23.3 Documet ay isertio of caula i patiet otes [As per trust protocol]. The radiographer will esure the followig is recorded o CRIS: Date Patiets ame Radiographer ad Supervisig Radiologists iitials Cotrast media type, volume used ad batch umber Reactio 13

14 Number of attempts at caulatio (This ca also be marked o the CRIS diagram) [See Appedix 4] 23.4 Ay adverse reactios to cotrast media must be recorded i the patiets otes (3) if available ad o CRIS with detail of their ature/severity/aget used (3). A alarm o CRIS should also be added. All cotrast reactios should be recorded i the radiological report (3) 23.5 Suspected adverse reactios should be reported o a Yellow Card to the MHRA (3)p12 This ca be doe by visitig the Yellow Card website ad fillig i the electroic form [See Appedix 5]. It is recommeded that this task is haded over to the Datix Ivestigatig Officer as this perso is more likely to have see similar submissios ad i some cases may idetify ad accumulative issue Where possible "peel off trackig labels foud o vials, syriges or bottles ad stick oto the patiet record (3)p Audit ad Moitorig 24.1 Ay issues of o-compliace should be reported to the lead CT radiographer so that ay traiig eeds ca be quickly resolved The radiographer must regularly audit their work, assessig first time accuracy for ijectios ad cotrast media reactios ad the maagemet of adverse effects of the examiatio All risk evets that have resulted i patiet harm or ear misses, must be reported o a Datix form. The Datix ivestigator will review all risk evets Ay immediate traiig or educatioal issues relatig to lack of compliace with this guidelie will be addressed o a oe-to-oe basis Refereces 1. Society ad College of Radiographers. Course of Study for the Certificatio of Competece i Admiisterig Itraveous Ijectios. Course of Study for the Certificatio of Competece i Admiisterig Itraveous Ijectios, secod editio Available from: 2. Royal College of Radiologists. Stadards for itra-vascular cotrast admiistratio to adult patiets, third editio Available from: 3. Royal College of Radiologists. Stadards for itra-vascular cotrast aget admiistratio to adult patiets, secod editio Available from: 4. NHS Choices. Dialysis - How it s performed Available from: [Accessed Jauary 2015]. 14

15 5. Uiversity of Califoria Sa Fracisco Departmet of Radiology ad Biomedical Imagig. Cotrast Extravasatio Available from: [Accessed September 2015]. 15

16 [APPENDIX 1: CENTRAL LINE FLOW CHART] 16

17 [APPENDIX 2: Questioaire for all patiets udergoig CT Scas Please, fill this i prior to you arrivig for your sca. Some of these questios will also be repeated i the CT room with you. Patiet details: First Name:... Surame:... Date of Birth:... First Lie of Address:... Post Code:... Hospital umber (If kow):... Questios (A): Please tick Do you have A allergy to x-ray cotrast? (also kow as cotrast media or dye) Kidey disease? (or have a poor kidey fuctio?) Hyperthyroidism? (also kow as a over-reactive thyroid) (3)p9 Are you Udergoig radio-iodie treatmet for thyroid cacer? If you have aswered yes, to ay of the questios above, please rig the cotact umber, at the ed of this questioaire. Yes No Questios (B): Please tick Do you have ay allergies? (3)p9 (Please list i box provided at ed of questioaire) have ay of these bee severe, requirig treatmet? (3)p9 Yes No Are you diabetic? (3)p9 asthmatic? (3)p9 experiecig ay thyroid coditios? Do you take ay of the followig medicatios? metformi? (3)p9 iterleuki-2? (3)p9 (also kow as Aldesleuki or IL-2) ephrotoxic drugs? blood-thiers? (e.g. Aspiri or Warfari) 17

18 First Name:... Surame:... Questios (C): Do you have Heart failure (3)p9? Other heart problems? Glaucoma? Uriary retetio (Problems passig water)? Myeloma? Please tur over for page 2 of the questioaire Yes No Questios (D): Do you have a fistula i your arm? Are you pregat? Are you breast-feedig? Have you had a mastectomy? Yes No How much do you weigh? (This may be used for medicatio calculatios) ===== END OF QUESTIONS ===== Please sig to cofirm you have read, uderstood ad aswered all of the questios. Your Sigature... Date: / / O behalf of patiet (Paret/Guardia/Close-Relative/Doctor) Relatioship/bleep... Name.. Sigature. Additioal commets box: Please ote: you might be required to drik a special cotrast drik (depedig o your sca) which may or may ot also iclude a ijectio of x-ray dye. If you have aswered yes, to ay of the questios i sectio (A), please rig the followig cotact umber betwee 09:00-17:00 for further advice: Tel: Thak you, Yours sicerely, The CT departmet (A201) Author: S.P

19 [APPENDIX 3:] Usig PICC lies Oly trust recogised CT safe CT PICC Lies that have bee iserted withi MEHT ca be used. Before the PICC lie ca be used for the admiistratio of CM it MUST: - Have bee iserted i MEHT - Be a Navilyst Medical PICC lie with PASV Valve techology - Have a purple (body) with "POWER INJECT 5ml/Sec MAX" writte o the body (Double lume ) OR POWER INJECT 3.5ml/Sec MAX writte o the body (Sigle lume) [Picture 1 - Below: Double lume PICC pressure rated at 5ml/sec MAX with a gauge of 16.5] [Picture 2 Below: Sigle lume PICC pressure rated at 3.5ml/sec MAX with a gauge of 17] 19

20 To use: Esure the PICC appears secure at the site (achored dow with dressig) [NB: it is very rare for them to kik] Use sterile gloves (Uiversal precautios) [as touchig the purple tip ca icrease the risk of blood bore ifectio] A woud-care sterile pack is also recommeded (alog with sterile drawig up eedle, 20ml syrige, bug, opeed sterets + salie) Scrub the PICC hub/ed with a steret (Avoid touchig tip of body with glove) Draw up a 20ml syrige with NaCl (Salie) A 20ml syrige must be used. Aspirate/draw back ad look for flashback Flush lie with salie 0.9% [Note pt will ot be able to feel flushig] Check that there is o resistace Keep dressig dry durig procedure to keep PICC Lie i situ Ijector pump: Flow rate must NOT exceed the stated flow rate that has bee explicitly prited oto the PICC lie body Pressure o the pump is ever expected to exceed 200 psi (Therefore the max PSI o the pump should be set to 200 or less to reduce risk) [NB: The maximum PSI ratig for these particular PICC lies is 300psi] The Covidie power ijector pump is to be used for PICC lies as this allows a costat PSI. A maximum PSI level ca also be set to reduce risk After the procedure: The lie must be flushed with Salie (20mls) Need ay guidace? - Phoe PICC team/ PICC urse (Julie Godfrey) if you have ay queries i hours - Phoe ITU Nurses if you eed ay help out of hours - Itervetioal Radiologists ofte have a wealth of experiece with PICC lies - Refer to DRAG protocol o itraet regardig PICC lies 20

21 [APPENDIX 4: AREA OF CANNULATION, CRIS MARKING TOOL] Whe doig details i post-processig, the followig widow sectio will appear towards the bottom of the page: Step oe: Select Plus (Successful Site Step two: Pick colour of caula. Click the Colour box ad select the colour. Press OK. 21

22 Step three: Select the site of veous access o the diagram. A cross will be marked whe completed. 22

23 [APPENDIX 5: YELLOW CARD MHRA] For more iformatio about the MHRA Yellow Card scheme please visit: To submit a suspected adverse reactio to the MHRA Yellow Card scheme please visit: 23

24 [APPENDIX 6:] CT & MRI VERSION 1 Stuart Craig & Dr P Lee PROCEDURE: Extravasatio of CT & MRI 27 th Jauary 2014 cotrast media To be reviewed Jauary 2015 Extravasatio of Cotrast Media durig CT ad MRI scas Extravasatio of pharmaceutical products followig IV caulatio is a recogised complicatio. Due to the rates, pressures ad volumes ivolved with cotrast media admiistratio it is imperative extravasatio of is idetified ad treated early to miimise complicatios. The followig procedure is i place for the effective treatmet ad moitorig of extravasatio withi the CT ad MRI departmet. Procedure to be udertake followig idetificatio of extravasatio Discoect patiet from ijectio pump. Leave caula i situ. Complete required examiatio as appropriate Elevate limb Apply ice pack to site of extravasatio Cotact duty radiologist Patiet ijury to be reviewed ad assessed by radiologist If symptoms do ot resolve quickly, admit ad moitor Ski blisterig, paraesthesisa, altered tissue perfusio ad icreasig pr persistet pai for more tha four hours suggest severe ijury is preset. If so, seek advice from plastic surgeo. Record iformatio regardig DATIX esurig volumes, maagemet of patiet ad radiologist are cosulted are icluded. For ipatiets oly, otify the team resposible ad record i otes Plastic surgeos Plastic surgeo advice is available o site ad should be cosulted promptly if treatmet does ot progress as expected. Outside of ormal workig hours As the duty radiologist is ot preset outside of ormal workig hours, this role should be substituted with the resposible attedig physicia for that patiet. The above advice ad iformatio should be made available to the resposible physicia. Moitorig Extravasatio rates recorded through DATIX will be moitored yearly. Ay sigificat icreases i rate will be ivestigated. Refereces The Royal College of Radiologists, 2010, Stadards for itravascular cotrast aget admiistratio to adult patiets Secod Editio, Lodo, The Royal 24

25 [APPENDIX 7: MANAGEMENT OF CONTRAST REACTIONS] 1 of 2 SOURCE: Royal College of Radiologists (RCR), 2015 Stadards for itravascular cotrast aget admiistratio to adult patiets", Third Editio The treatmet of reactios Simple guidelies for the treatmet of reactios are preseted below. Nausea/vomitig Trasiet: supportive treatmet. Severe, protracted: appropriate ati-emetic drugs should be cosidered. Urticaria Scattered, trasiet: supportive treatmet, icludig observatio. Scattered, protracted: appropriate H1-atihistamie itramuscularly, orally or itraveously should be cosidered. Drowsiess ad/or hypotesio may occur. Profoud: cosider adrealie 1:1000, ml ( mg) itramuscularly. Repeat, as eeded. Brochospasm Oxyge by mask (6 10 l/mi). β-2-agoist metered dose ihaler (2 3 deep ihalatios). Adrealie: Elevate patiets legs. Normal blood pressure: adrealie 1:1000, ml ( mg) itramuscularly. Use smaller dose i a patiet with coroary artery disease or elderly patiet Decreased blood pressure: adrealie 1:1000, 0.5 ml (0.5 mg) itramuscularly. Larygeal oedema Oxyge by mask (6 10 l/mi). Adrealie 1:1000, 0.5 ml (0.5 mg) itramuscularly. Repeat, as eeded. Hypotesio Isolated hypotesio: Oxyge by mask (6 10 l/mi) Itraveous fluid: rapidly, ormal salie or lactated Riger s solutio If uresposive: adrealie 1:1,000, 0.5 ml (0.5 mg) itramuscularly. Repeat, as eeded. Vagal reactio (hypotesio ad bradycardia): Elevate patiet s legs Oxyge by mask (6 10 l/mi) Atropie mg itraveously, Repeat, if ecessary, after 3 5 miutes, to 3 mg total (0.04 mg/kg) Itraveous fluids: rapidly, ormal salie or lactated Riger s solutio 25

26 [APPENDIX 7: MANAGEMENT OF CONTRAST REACTIONS] 2 of 2 Geeralised aaphylactoid reactio Call for resuscitatio team. Suctio airway, if eeded. Elevate patiet s legs, if hypotesive. Oxyge by mask (6 10 l/mi). Adrealie: 1:1000, 0.5 ml (0.5 mg) itramuscularly. H1 blocker, for example, diphehydramie mg itraveously. Cotrast medium extravasatio Record details of the icidet with maagemet advice i the report ad otes. Elevate the affected limb. Apply ice packs to the affected area. If symptoms resolve such that a outpatiet ca be allowed home, supply the patiet with a appropriate advice leaflet. If symptoms do ot resolve quickly, admit ad moitor. Ski blisterig, paraesthesia, altered tissue perfusio ad icreasig or persistet pai >4 hours suggest severe ijury. If so, seek surgical advice (plastic surgeo). Delayed ski reactios Ski reactios have bee reported up to a week after the admiistratio of cotrast medium. Symptomatic treatmet oly is required. The reactio should be recorded i the patiet s record, but it is the case that the status ad sigificace of these reactios are ucertai. 26

27 [APPENDIX 8: BREAST FEEDING WITH NIOPAM] 1 of 1 Niopam: breast feedig va Gessel Rolad [Rolad.Vagessel@bracco.com] o behalf of Services Professioal Europe [Services.ProfessioalEurope@bracco.com] Set: 15 July :30 To: Pery Sam (RQ8) Mid Essex Hospital Cc: Morris Hele [Hele.Morris@bracco.com]; Alessadro Silvia [Silvia.Alessadro@bracco.com] Dear Mr Pery, Thak you for cotactig Bracco UK with your query regardig breast feedig whe beig examied with Niopam (active igrediet: Iopamidol. O behalf of the Bracco Professioal Services Europe I am glöad to provide the followig iformatio: The effective Niopam ) Summary of Product Characteristics (SPC; Jue 2015) stipulates i sectio 4.6 (Fertility, pregacy ad) lactatio: Iodie-cotaiig X-ray cotrast agets are excreted ito the breast milk i low amouts. From aimal experiece, Niopam is o toxic i aimals after oral admiistratio. From experiece gaied so far, harm to the ursig ifat is ulikely to occur. Stoppig breastfeedig is uecessary. Because (strogly hydrophilic) Iopamidol does ot accumulate i hydrophobic milk (< 1%) ad, after oral itake of the milk by the ifat, absorptio from the GI tract is miimal (agai < 1%), Iopamidol does ot eter the ifat s systemic circulatio at sigificat amout (less tha 0.01% of the origially admiistered dose), there is o eed to iterrupt breast feedig. I hope this aswers your questio. Should you eed additioal iformatio, please do ot hesitate to cotact services.professioaleurope@bracco.com. Sicerely, Rolad va Gessel Rolad va Gessel, PhD, MSc Seior Director Head, Professioal Services Europe Iformatio Officer Bracco Imagig Deutschlad Max-Stromeyer-Str Kostaz Germay tel +49 (0) fax +49 (0) rolad.vagessel@bracco.com services.professioaleurope@bracco.com 27

28 [APPENDIX 9: EXTRAVASATION ADVICE LEAFLET] Patiet Iformatio CT Departmet Extravasatio Patiet Aftercare Leaflet This leaflet cotais further iformatio o what you should do if the cotrast ijectio that you were give for your CT sca has leaked out uder your ski (extravasatio). What is extravasatio? Occasioally the ijectio may iadvertetly leak out from the vei to the tissues uder the ski this is kow as extravasatio. If this has happeed, you will experiece a stigig sesatio where the cotrast has goe ito the tissue ad it ca be paiful. This will usually wear off after about 30 miutes, i which case you may leave the departmet with this advice leaflet. Is there aythig I ca do at home? Massage the area where the cotrast has goe ito the tissue. If there is swellig: elevate the affected arm as much as possible. At ight, keep it elevated o two pillows (you should cotiue to do this util the swellig has goe dow.) apply a ice-pack wrapped i a clea tea towel over the site itermittetly, for o more tha 15 miutes at a time. If the area is paiful, take your usual paikillers. Is there aythig I eed to look out for? I most cases this is a mior ijury ad does ot require ay treatmet. However If the followig persists for more tha four hours this would suggest a severe ijury ad you must retur to the hospital Icreased swellig or pai Icreased Redess Chage i sesatio i the affected limb Ski ulceratio or blisterig 28

29 Patiet Iformatio To be completed by the CT radiographer Date ad time Cotrast Aget Site of extravasatio Amout of cotrast extravasated Amout of salie extravasated Cotacts / Further Iformatio If you would like further iformatio, regardig the evidece prited i this leaflet please cotact a Seior CT Radiographer o or refer to: All coflicts of iformatio have bee disclosed prior to the developmet of this Patiet Iformatio Leaflet. Please ask if you require this iformatio i other laguages, large prit, easy read accessible iformatio, audio/visual, sigig, pictorial ad chage picture bak forma via the Patiet Advisory Liaiso Service (PALS) o (01245) Mid Essex Hospital services NHS Trust is smoke-free. You caot smoke o site. For advice o quittig, cotact your GP or the NHS smokig helplie free, Charitable doatios ca make a very real differece to the level of patiet care at our Trust. As well as cotributig to ew facilities, doatios ca be used to buy specialist equipmet ad smaller items to make patiet s stay i hospital more comfortable. For iformatio about makig a doatio please cotact the Charities Office o or visit the website at: Documet History CT Departmet Published/Review: File ame: S:\RadiologyDept\Radiology\Departmetal Folders\MODALITIES\CT\Forms Versio/ref o 1 29

30 [APPENDIX 10: PICC LINE TESTING WITH THE COVIDIEN PUMP] Sigle lume Bi-lume Substace Max Flow rate (ml/s) stated o PICC body Chose flow rate tested o pump IV CM IV CM PSI (outcome) IV CM 30

31 [APPENDIX 11: A TABLE TO SUMMARISE THE BREAST FEEDING GUIDANCE FOR COMMONLY USED CONTRAST MEDIUMS (FROM RCR AND MANUFACTURES) IV Cotrast Media RCR (2015) Maufacture Source of /for further iformatio Visipaque No special precautios required Ca cotiue breastfeedig ormally See maufacture guidace i product box Niopam No special precautios required Ca cotiue breastfeedig ormally [See Appedix 8] Optiray (Iversol) No special precautios required Discotiue for oe day See maufacture guidace i product box 31

32 [APPENDIX 12: A LOOK-UP TABLE TO SHOW VOLUMES FOR PORTAL VENOUS IMAGING] Weight (KG) 300 stregth cotrast 340 stregth cotrast Volume (mls) 350 stregth cotrast 370 stregth cotrast * * 150* 150* * = Limited/Max volume. 32

33 [APPENDIX 13: A LOOK-UP TABLE TO SHOW FIXED VOLUMES FOR LISTED CT EXAMINATIONS] Examiatio CTPA Arterial Chest oly Head + C Volume 75mls 75mls 50mls 33

34 [APPENDIX 14: CAMP BASTION CONTRAST WHEEL CALCULATOR] 34