MANUAL ON CONTRAST MEDIA VERSION 7 2010 Quality is our Image™ Table of Contents TOPIC Preface ............................................................................................................................... Introduction ....................................................................................................................... Patient Selection and Preparation Strategies ...................................................................... Injection of Contrast Media ................................................................................................ Extravasation of Contrast Media ....................................................................................... Incidence of Adverse Effects .............................................................................................. Adverse Effects of Iodinated Contrast Media .................................................................... Contrast Nephrotoxicity ..................................................................................................... Metformin ........................................................................................................................ Contrast Media in Children ............................................................................................... Iodinated Gastrointestinal Contrast Media: Indications and Guidelines ............................. Adverse Reactions to Gadolinium-Based Contrast Media ................................................. Nephrogenic Systemic Fibrosis .......................................................................................... Treatment of Contrast Reactions........................................................................................... Administration of Contrast Medium to Pregnant or Potentially Pregnant Patients ............. Administration of Contrast Medium to Breast-Feeding Mothers.......................................... Table 1: Indications for Use of Iodinated Contrast Media .................................................... Table 2: Organ or System-Specific Adverse Effects .......................................................... Table 3: Categories of Reactions ........................................................................................ Table 4: ABCD Approach for Patient Evaluation and Treatment ..................................... Table 5: Pediatric Dose Schedules .................................................................................... Table 6: Management of Acute Reactions in Adults ........................................................... Table 7: Equipment for Emergency Carts ........................................................................... APPENDIX A: Contrast Media Specifications .................................................................. Manual on Contrast Media – Version 7, 2010 Table of Contents PREFACE This Seventh Edition of the ACR Manual on Contrast Media replaces all earlier editions. It is being published as a Web-based document only so it can be updated as frequently as needed. This manual was developed by the ACR Committee on Drugs and Contrast Media of the ACR Commission on General, Small and/or Rural Radiology as a guide for radiologists to enhance the safe and effective use of contrast media. Suggestions for patient screening, premedication, recognition of adverse reactions, and emergency treatment of such reactions are emphasized. Its major purpose is to provide useful information regarding contrast media used in daily practice. The committee offers this document to practicing radiologists as a consensus of scientific evidence and clinical experience concerning the use of iodinated contrast media. The general principles outlined here also pertain to the administration and systemic effects (e.g., adverse effects) of noniodinated contrast media such as gadolinium or other compounds used for magnetic resonance imaging, as well as to the use of iodinated contrast media for gastrointestinal imaging. The editorial staff sincerely thanks all who have contributed their knowledge and valuable time to this publication. Members of the ACR Committee on Drugs and Contrast Media at the time of this edition are: Richard Cohan, MD, Chair Syed Jafri, MD Peter Choyke, MD Jeffrey Newhouse, MD Mervyn Cohen, MD Carl Sandler, MD Matthew Davenport, MD Arthur Segal, MD Jonathan Dillman, MD Claude Sirlin, MD James Ellis, MD Neil Wasserman, MD Robert Hartman, MD The ACR Committee on Drugs and Contrast Media wishes to thank the following members of the ACR Subcommittee on MR Safety for their assistance in producing the new Joint Chapter on Nephrogenic Systemic Fibrosis (NSF): Emanuel Kanal, MD, Chair J. Rod Gimbel, MD A. James Barkovich, MD John Gossbee, MD James P. Borgstede, MD James Lester, MD William G. Bradley, MD John Nyenhuis, PhD Jerry W. Froelich, MD Jeffrey Weinreb, MD Finally, the committee wishes to recognize the efforts of Ms. Margaret Wyatt and other supporting members of the ACR staff. Manual on Contrast Media – Version 7, 2010 Preface / 1 INTRODUCTION Various forms of contrast media have been the referring physician and the radiologist used to improve medical imaging. Their include: value has long been recognized, as attested to by their common daily use in imaging 1. Assessment of patient risk versus departments worldwide. Like all other potential benefit of the contrast pharmaceuticals, however, these agents are assisted examination. not completely devoid of risk. The major 2. Imaging alternatives that would purpose of this manual is to assist provide the same or better radiologists in recognizing and managing diagnostic information. the small but real risks inherent in the use of 3. Assurance of a valid clinical contrast media. indication for each contrast medium administration. Adverse side effects from the administration of contrast media vary from minor Because of the documented low incidence of physiological disturbances to rare severe adverse events, intravenous injection of life-threatening situations. Preparation for contrast media may be exempted from the prompt treatment of contrast media reactions need for informed consent, but this decision must include preparation for the entire should be based on state law, institutional spectrum of potential adverse events and policy, and departmental policy. include prearranged response planning with availability of appropriately trained Usage Note: In this manual, the term “low- personnel, equipment, and medications. osmolality” in reference to radiographic Therefore, such preparation is best iodinated contrast media is intended to accomplished prior to approving and encompass both low-osmolality and iso- performing these examinations. osmolality media, the former having Additionally, an ongoing quality assurance osmolality approximately twice that of and quality improvement program for all human serum, and the latter having radiologists and technologists and the osmolality approximately that of human requisite equipment are recommended. serum at conventionally used iodine Thorough familiarity with the presentation concentrations for vascular injection. Also, and emergency treatment of contrast media unless otherwise obvious in context, this reactions must be part of the environment in manual focuses on issues concerning which all intravascular contrast media are radiographic iodinated contrast media. administered. Millions of radiological examinations assisted by intravascular contrast media are conducted each year in North America. Although adverse side effects are infrequent, a detailed knowledge of the variety of side effects, their likelihood in relationship to pre-existing conditions, and their treatment is required to insure optimal patient care. As would be appropriate with any diagnostic procedure, preliminary considerations for Manual on Contrast Media – Version 7, 2010 Introduction / 1 PATIENT SELECTION AND PREPARATION STRATEGIES General Considerations allergies, such as a prior major anaphylactic response to one or more allergens. The approach to patients about to undergo a contrast-enhanced examination has three The predictive value of specific allergies, general goals: 1) to assure that the such as those to shellfish or dairy products, administration of contrast is appropriate for previously thought to be helpful, is now the patient and the indication; 2) to recognized to be unreliable [2-3] A minimize the likelihood of a contrast significant number of health care providers reaction; and 3) to be fully prepared to treat continue to inquire specifically into a a reaction should one occur (see Table 4). patient’s history of “allergy” to seafood, Achieving these aims depends on obtaining especially shellfish [4]. There is no evidence an appropriate and adequate history for each to support the continuation of this practice patient, preparing the patient appropriately [4-5]. for the examination, having equipment available to treat reactions, and ensuring that Any patient who describes an “allergy” to a expertise sufficient to treat even the most food or contrast media should be questioned severe reactions is readily at hand. Although further to clarify the type and severity of the mild reactions to contrast media are “allergy” or reaction, as these patients could relatively common, they are almost be atopic and at increased risk for reactions invariably self-limited and of no [2]. Most forms of atopy result in a 2 to 3 consequence. Severe, life-threatening times likelihood of