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CLINICAL PRACTICE PROFESSIONAL GUIDELINE Radiopaque Contrast Media
DATE OF ISSUE:
13 (Appendix) NUMBER:
ISSUED BY:
SUPERCEDES:
ISSUED BY:
Purpose:
To provide a guideline to assist Physicians in the management of patients who are scheduled for
Radiology tests involving Radiopaque contrast media (RCM) at The Credit Valley Hospital. This
guideline focuses on prevention and treatment of adverse reactions such as anaphylactoid
reactions and nephrotoxicity.
Selection Criteria:
Inclusion
• all patients receiving RCM at The Credit Valley Hospital - see Appendix 1 for a list of CT scans I. PREVENTION OF RADIOCONTRAST REACTIONS (1,2)
See Appendix 2, Prevention of Radiopaque Contrast Media Reactions A. Identifying Patients at Risk
1. High-Risk Patients (Pretreatment Recommended)
Consult with Radiologist prior to study to see if alternate imaging procedure without RCM is available. Previous anaphylactoid reaction occurring within 20-30 minutes of administering RCM (one or more of the following): • documented laryngeal edema or voice change • hypotension (decrease in SBP of > 30 mm Hg) Radiopaque Contrast Media
• cardiac dysrhythmia associated with urticaria or angioedema 2. Low-Risk or No Risk (Pretreatment NOT Recommended)
• parotid swelling following RCM
• reaction of any type to iodide or iodine 3. Asthma and/or Atopy
This large group of patients is generally at low-risk but each patient needs individual assessment. It is assumed that the more severe the allergic condition (eg. asthma, allergic rhinitis, drugs, foods, multiple allergies and foreign proteins (venoms, latex)), the greater the patient's atopic reactivity, and thus the greater the risk of any antigen. These patients will be evaluated for individual risk by the attending radiologist, ie will be placed in a low or high-risk category and a decision made regarding the need for pretreatment. B. Pretreatment Protocol
1. Elective
Procedures
Prednisone 50 mg orally to be given 13 hours, 7 hours and 1 hour prior to RCM. Diphenhydramine 50 mg orally/IM/IV to be given 1 hour prior to RCM. Paediatrics: prednisone or prednisolone liquid 1 mg/kg/dose (max 50 mg) orally to be given 13 hours, 7 hours and 1 hour prior to RCM. Diphenhydramine 1 mg/kg/dose (max 50 mg) orally/IM/IV to be given 1 hour prior to RCM. If the patient cannot be given oral prednisone 50 mg, one of the following equivalent doses of parenteral corticosteroid can be substituted: hydrocortisone sodium succinate (Solu-Cortef) 200 mg ( Paediatrics: 5 mg/kg) OR methylprednisolone sodium succinate (Solu-Medrol) 40 mg (Paediatrics: 1-2 mg/kg) 2. Emergency Procedures (when 13 hours of pretreatment is not possible) (2,11)
Hydrocortisone sodium succinate (Solu-Cortef) 200 mg (Paediatrics: 5 mg/kg, max 200 mg) IV as soon as the procedure is judged essential and repeat q4h until the procedure is complete. Diphenhydramine (Benadryl) 50 mg (Paediatrics: 1 mg /kg, max 50 mg) IM or IV, 1 hour before RCM. Radiopaque Contrast Media
II. TREATMENT OF RCM REACTIONS
A. Generalized Anaphylactoid Reaction (3,11)
1. Call for assistance 2. Suction airway as needed 3. Oxygen 100% by mask (6-10 L/min) 4. Epinephrine* (SC, IV or IT - see methods of administration and dosing below) 5. Normal Saline IV 6. Diphenhydramine (Paediatrics: 1-2 mg/kg, max 50 mg) IV 7. Salbutamol inhaler 100 ug/inhalation for persistent bronchospasm: 2-3 inhalations 8. Ranitidine 50 mg (Paediatrics: 2.5 mg/kg/dose (max 50 mg)) IV Alternatives for epinephrine for patients taking beta blockers:
glucagon 1-5 mg IV as a bolus followed by infusion of 5-15 ug/min, isoprenaline (isoproterenol): 1:5000 solution for inj (0.2 mg/mL) IV, 0.5-1 mL diluted to 10 mL with NS, 1 mL (20 ug) increments. For patients with bronchospasm or undergoing prolonged resuscitation or severe reaction: hydrocortisone sodium succinate (Solu-Cortef) 100 mg IM/IV q3-6h for 2-4 doses
(Paediatrics: 6 mg/kg/dose IM/IV q4-6h for 2-4 doses)
OR
methylprednisolone sodium succinate (Solu-Medrol) 40-125 mg IV q6h for 2-4 doses
(Paediatrics: 1 mg/kg/dose IV q6h for 2-4 doses)
Radiopaque Contrast Media
Epinephrine – Methods of Administration and Dosing
Subcutaneous Injection
The emergency treatment of an anaphylactoid reaction consists of the subcutaneous injection of
0.1 to 0.3 mL of 1:1000 (1 mg/mL) epinephrine; this may be repeated q15min x 2 (total of 1 mg). (2)
(Paediatrics: 1:1,000 (1 mg/mL) strength – 0.01 mg/kg/dose (0.01 mL/kg/dose) SC (minimum 0.1 mL/dose; max 1 mL/dose), may repeat once in 5 min. (4) Intravenous Injection
A slow IV injection of 1:10,000 (1 mg/10 mL) epinephrine has been recommended for failure of the
subcutaneous route or if peripheral vascular collapse is present. In such situations, begin with 1
mL of epinephrine 1:10,000 which may be repeated every 1 to 5 minutes until a total of 1 mg (10
mL) has been administered. (2)
(Paediatrics: 1:10,000 (0.1 mg/mL) strength – 0.01 mg/kg/dose (0.1 mL/kg/dose) IV (minimum 1 mL/dose; max 10 mL/dose), may repeat once in 5 min. (4) Other Methods of Administration
In an emergency, epinephrine can be administered via the airway (inhaled, transtracheal,
endotracheal). (3) The recommended dose is 3-5 mL of 1:10,000
(0.3-0.5 mg) intratracheally q10-20 min prn. (5)
(Paediatrics: 1:10,000 (0.1 mg/mL) strength – 0.01 mg/kg/dose (0.1 mL/kg/dose) ETT (minimum 1 mL/dose; max 10 mL/dose), may repeat once in 5 min. (4) B. Urticaria (3,11)
Treatment is usually not necessary for only a few scattered hives or pruritus. However, the patient should be observed closely for other developing systemic symptoms, while maintaining IV access. Only if the urticaria is extensive or bothersome to the patient should treatment be instituted. (Paediatrics: 1.25 mg/kg) IV or IM q2-3h (Paediatrics: 1.25 mg/kg) IV or IM q2-3h 2. Ranitidine 50 mg IV q8h (Paediatrics: total daily dose 2-4 mg/kg divided q6-8h) 3. Consider Radiopaque Contrast Media
C. Treatment of Hypotension/Bradycardia (3,11)
• monitors in place: ECG, pulse oximeter, BP • IV fluid - rapid administration of NS • if unresponsive: vasopressor eg. dopamine, norepinephrine or epinephrine Vagal reaction (hypotension and bradycardia) • monitors in place: ECG, pulse oximeter, BP • IV fluid - rapid administration of NS • Atropine 0.6-1 mg IV, repeat if necessary after 3-5 min to 3 mg total • (Paediatrics: give 0.02 mg/kg IV (up to a max of 0.6 mg per dose); repeat if necessary to a total D. Treatment of Severe Hypertension (10)
• monitors in place: ECG, pulse oximeter, BP • labetolol 20-80 mg IV q10-15 min (max total dose 300 mg) (Paediatrics: 1-3 mg/kg IV single dose or 1mg/kg/h continuous IV infusion)(11) • Adults: consider nitroglycerin (for MI), hydralazine (for hypertension of pregnancy) III. PREVENTION OF LACTIC ACIDOSIS IN PATIENTS RECEIVING METFORMIN
See Appendix 3 - Guidelines for Prevention of Lactic Acidosis in Patients Receiving Metformin and Radiopaque Contrast Media Patients who are scheduled for Radiopaque contrast media and who are taking metformin should have a baseline serum creatinine performed prior to receiving RCM. Metformin should be held following RCM. Serum creatinine should be repeated when possible at 48 hours or as soon as possible after that. If creatinine has not increased greater than 10% over baseline, metformin may be restarted.(6,7) If creatinine elevation is prolonged or persistent, follow-up with the family physician or an appropriate specialist is recommended. A Medical Directive for management of outpatients has been developed. For inpatients, the Radiologist will write orders in the patient chart following the administration of RCM – “Radiology suggests hold metformin until 48 hour creatinine is reviewed. May resume metformin if creatinine has not risen>10%, contact MRP if it has.” Radiopaque Contrast Media
IV. PREVENTION OF RADIOPAQUE CONTRAST MEDIA - INDUCED
NEPHROTOXICITY (3,8,12)
Risk Factors for Radiopaque Contrast Media-Induced Nephrotoxicity:
• concomitant use of certain drugs (Angiotensin Converting Enzyme Inhibitors (ACEIs), Angiotensin Receptor Blockers (ARBs), Nonsteroidal Antiinflammatory Drugs (NSAIDs), aminoglycosides, cisplatin) • dehydration (consider holding diuretics) • multiple RCM studies (suggested minimal interval between dye exposures - 48 h) If risk factors identified in adult patients see Appendix 4 - Guidelines for Prevention of Radiopaque Contrast Media -Induced Nephrotoxicity for Adults If risk factors identified in paediatric patients consult Paediatrics and Radiology. Patients with diabetes with even mild degrees of renal insufficiency are at risk of developing
radiocontrast-induced nephropathy (RCIN).
In one study acetylcysteine has been shown to be effective in preventing renal impairment when
given prophylactically along with hydration in patients with chronic renal insufficiency. (9)
For patients considered to be at risk for nephrotoxicity, the patient should be hydrated and acetylcysteine administration considered. Following administration of RCM, creatinine should be measured at 48 hours. Radiopaque Contrast Media
Evaluation:
Following implemenation of the guideline, an evaluation will be carried out to measure the following:
• for high risk patients – availability of creatinine from ordering physician, number of • for metformin patients – what were follow-up creatinines and was medical follow-up necessary • adverse reactions – track to see if increased premedication reduces adverse events References:
1. Ellenhorn MJ. Ellenhorn’s Medical Toxicology, 2nd ed. 1999; 1305-1320. 2. Sunnybrook and Women's College Health Sciences Centre, Formulary and Drug Use Guidelines and Policies, December, 1999. 3. Thomsen HS, Bush WH. Adverse Effects of Contrast Media, Incidence, Prevention and Management. Drug Safety 1998; 19: 313-324. 4. Dipchand AI (ed). The HSC Handbook of Pediatrics, 9th edition, 1997. 5. Young LY, Koda-Kimble MA, eds. Applied Therapeutics: the clinical use of drugs, 6th ed. 1995: 6-4 6. Wellbanks L, ed. CPS, 36th ed. Toronto-Webcom Ltd, 2001: 636-638. 7. Rasuli P, Hammond DI. Metformin and contrast media: where is the conflict? Canadian Association of Radiologists Journal. 1998; 49: 161-166. 8. Solomon R. Radiocontrast-Induced Nephropathy. Seminars in Nephrology. 1998; 18: 9. Tepel M, van der Giet M, Schwarzfeld C et al. Prevention of radiographic-contrast- agent-induced reductions in renal function by acetylcysteine. NEJM. 2000; 343:180-4. 10. Hypertensive Crisis. Micromedex Healthcare Series Vol 109, Sept 2001. 11. Holmes JL, Roy R (eds). Formulary of Drugs The Hospital for Sick Children, 19th 12. Waybill MM, Waybill PN. Contrast Media-induced nephrotoxicity: identification of patients at risk and algorithms for prevention. J Vasc Interv Radiol. 2001; 12:3-9. Approval:
Department of Imaging: January 2002 Surgical Steering Committee: February 2002 Paediatric Steering Committee: February 2002 ER Steering Committee: February 2002 General Medicine Steering Committee: February 2002 Pharmacy and Therapeutics Committee: March 2002 Professional Practice Committee: April 2002 Clinical Quality Care Committee: April 2002 Medical Advisory Committee: May 2002 Clinical Indications for CT Exams
Unenhanced CT’s (no RCM administered):
- stroke, rule out bleed - rule out subarachnoid hemorrhage - headache, no neurologic findings - investigation of infectious sinus - facial bone fractures - TM joints - middle ear pathology and - cervical spine fractures - other bony spinal canal pathology - investigation of pulmonary nodules for - bronchiectasis - interstitial lung disease - abdomen pain NYD - renal colic - lymphoma follow up - rule out disc herniation or stenosis - rule out bone lesion - assess for fracture - assessment of fractures - assessment of bone lesions Enhanced CT Examinations (RCM administered):
- tumor assessment - investigation of seizures - orbital pathology - acoustic neuromas - Circle of Willis (CTA) - assessment of masses - tumor evaluation - carotid/vertebral CT angiogram - evaluation and staging of tumors - aneurysm assessment - aortic dissection - pulmonary CTA for embolism - investigation, staging and follow up of - assessment of liver lesions - assessment of kidney lesions - assessment of pancreatitis - abdominal aortic aneurysm - rule out abscess - adrenal mass assessment * In case of any doubt contact a Radiologist. Prevention of Radiopaque Contrast Media Reactions
Are alternate
available?
Proceed with
Proceed with
pretreatment*
alternate test
Proceed with
give pretreatment*
and proceed with RCM
*Pretreatment:
1. Elective
Procedures
Prednisone 50 mg orally to be given 13 hours, 7 hours and 1 hour prior to RCM. Diphenhydramine 50 mg orally/IM/IV to be given 1 hour prior to RCM. Paediatrics: prednisone or prednisolone liquid 1 mg/kg/dose (max 50 mg) orally to be given 13 hours, 7 hours and 1 hour prior to RCM. Diphenhydramine 1 mg/kg/dose (max 50mg) orally/IM/IV to be given 1 hour prior to RCM. If the patient cannot be given oral prednisone 50 mg, one of the following equivalent doses of parenteral corticosteroid can be substituted: hydrocortisone sodium succinate (Solu-Cortef) 200 mg (Paediatrics: 5 mg/kg) OR methylprednisolone sodium succinate (Solu-Medrol) 40 mg (Paediatrics: 1-2 mg/kg) 2. Emergency
Procedures
(When 13 hours of pretreatment is not possible)
Hydrocortisone sodium succinate (Solu-Cortef) 200 mg (Paediatrics: 5 mg/kg) IV as soon as the procedure is judged essential and repeat q4h until the procedure is complete. Diphenhydramine (Benadryl) 50 mg (Paediatrics: 1 mg /kg) IM or IV, 1 hour before RCM. Guidelines for Prevention of Lactic Acidosis in Patients
Receiving Metformin and Radiopaque Contrast Media
obtain serum
creatinine (baseline) *
proceed with RCM
hold metformin
repeat serum
creatinine at 48 h**
continue to hold metformin until creatinine returns to baseline * If patient’s creatinine is >120 umol/L, follow algorithm in Appendix 4 in addition to this
** serum creatinine should be repeated when possible at 48 hours or as soon as Guidelines for Prevention of Radiopaque Contrast Media Induced Nephrotoxicity
for Adults (3,8,12)
Obtain serum creatinine in patients at risk (see below) *Guidelines for Hydration
• for inpatients, give 0.45% NS infused at 1 mL/kg/h overnight prior to RCM and then continued for at least 8 h following RCM • for outpatients, give 0.45% NS @ 100 mL/h for 3-4 h before the procedure and continue at • if patients can drink, the hydration may be given orally **Acetylcysteine (9)
• dose 600 mg orally twice daily on the day before and the day of administration of the
RCM
note: Acetylcysteine (Mucomyst, Parvolex) is only available in injectable form. To prepare
the oral dose, withdraw 600 mg (3 mL) from the multidose vial and mix in a soft drink. Use
within one hour of mixing.
Other Risk Factors for Radiocontrast-Induced Nephrotoxicity:
• pre-existing renal failure
• concommittant use of certain drugs (Angiotensin Converting Enzyme Inhibitors (ACEIs), Angiotensin Receptor Blockers (ARBs), Nonsteroidal Antiinflammatory Drugs (NSAIDs), aminoglycosides, cisplatin) • dehydration (consider holding diuretics) • multiple RCM studies (suggested minimal interval between dye exposures - 48 h)

Source: http://www.cvh.on.ca/pro/cpg/CPG%2019-2%20Radiopaque%20Contrast%20Media.pdf