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Standards for Intravascular Contrast Administration to Adult Patients

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Standards for Intravascular Contrast Administration to Adult Patients www.rcr.ac.uk Standards for intravascular contrast administration to adult patients Third edition Faculty of Clinical Radiology Standards for intravascular contrast 2 www.rcr.ac.uk administration to adult patients Contents Renal function monitoring 10 Renal impairment 10 Foreword 3 Perioperative liver transplantation period 11 Recommended standards 4 Breastfeeding 11 Pregnancy 11 1. Introduction 5 Haemodialysis 11 2. General safety issues 5 Recording of the agent used 11 3. Practical safety issues 5 10. The treatment of reactions 11 4. Prescribing contrast 6 Nausea/vomiting 11 Ur ticaria 11 5. Patient information and consent 6 Bronchospasm 11 6. Identifying patients at increased risk Laryngeal oedema 12 from contrast administration 7 Hypotension 12 7. Recommendations for contrast use in patients at Generalised anaphylactic reaction 12 increased risk 7 Recording and investigation of significant History of previous contrast reaction 7 suspected contrast reactions 12 Asthma 7 Contrast medium extravasation 12 Multiple allergies or a documented severe allergy Delayed skin reactions 13 requiring therapy 8 11. Conclusion 13 Renal disease, diabetes mellitus and conditions associated with renal impairment 8 References 14 Risk factors for acute kidney injury in adults Appendix 1. Contrast-induced acute receiving iodinated contrast media 8 kidney injury 16 Metformin 9 Appendix 2. Chronic kidney disease stages 17 8. Other special cases 9 Appendix 3. Clinical features and clinicopathological Pregnancy 9 definition of NSF 18 Lactation 9 Thyroid 9 Appendix 4. European Medicines Agency classification Interleukin-2 treatment 9 of gadolinium-based contrast agents 20 9. Gadolinium contrast agents 10 Appendix 5. Definitions of confounded and Advice 10 unconfounded cases of contrast reaction 21 RCR Standards The standards are not regulations governing practice but attempt to define the aspects of radiological The Royal College of Radiologists (RCR), a registered services and care which promote the provision of a charity, exists to advance the science and practice of high-quality service to patients. radiology and oncology. All of the standards produced by the RCR can be found It undertakes to produce standards documents to on the College website www.rcr.ac.uk/standards provide guidance to radiologists and others involved in the delivery of radiological services with the aim of Francis classification of RCR Standards improving the service for the benefit of patients by defining best practice, and promoting advances in • Fundamental standards of minimum safety and quality practice. in respect of which non-compliance should not be tolerated. Failures leading to death or serious harm The standards documents cover a wide range of topics. should remain offences for which prosecution can be All have undergone an extensive consultation process to brought against organisations. There should be a ensure a broad consensus, underpinned by published defined set of duties to maintain and operate an evidence where applicable. Each is subject to review effective system to ensure compliance. four years after publication or earlier if appropriate. • Enhanced quality standards: such standards could set The RCR has committed to reviewing all relevant requirements higher than the fundamental standards, publications in line with the recommendations of the but would be discretionary matters for commissioning Francis report and, where appropriate, applying the and subject to availability of resources. category of standard defined by Francis (fundamental, enhanced or developmental).1 This document contains • Developmental standards which set longer term goals standards that fall within the enhanced category. for providers: these would focus on improvements in effectiveness and are more likely to be the focus of commissioners.1 Standards for intravascular contrast Standards for intravascular contrast administration to adult patients administration to adult patients www.rcr.ac.uk 3 Foreword These revised guidelines are necessary because of the ever-changing literature about both iodinated contrast media and gadolinium-based contrast agents (GBCAs). The RCR would like to thank the original authors, Professors Sameh Morcos and Peter Dawson, along with Dr Mark Downes, Dr Giles Roditi, Dr Andrew Lewington (Renal Association) and Dr Grant Baxter, who were largely responsible for this revision. The RCR would also like to thank the members of the Professional Support and Standards Board (PSSB) who made significant contributions. This document replaces Standards for intravascular contrast administration to adult patients, second edition (BFCR[10]4) and Gadolinium-based contrast media and nephrogenic systemic fibrosis (BFCR[07]14) which have been withdrawn. These standards fall within the enhanced category as defined by the Francis report, see RCR Standards (page 2).1 Richard FitzGerald Vice-President, Clinical Radiology The Royal College of Radiologists Current standards documents Standards for the provision of an significant radiological findings, Standards for the recording of second ultrasound service Second edition opinions or reviews in radiology departments Standards of practice of computed Standards for patient consent particular tomography coronary angiography to radiology, Second edition Standards for a results (CTCA) in adult patients acknowledgement system Standards of practice and guidance for Cancer multidisciplinary team meetings trauma radiology in severely injured Standards for providing a 24-hour – standards for clinical radiologists, patients diagnostic radiology service Second edition Standards and recommendations for the Standards for providing a 24-hour Standards for Learning from reporting and interpretation of imaging interventional radiology service Discrepancies meetings investigations by non-radiologist Standards for Self-assessment of medically qualified practitioners and Standards for radiofrequency ablation Performance teleradiologists (RFA), Second edition Standards for the Reporting and Standards for the NPSA and RCR safety Standards for patient confidentiality and Interpretation of Imaging investigations checklist for radiological interventions PACS and RIS Standards for Ultrasound Equipment Standards for the provision of Standards for the communication of teleradiology within the United critical, urgent and unexpected Kingdom Standards for intravascular contrast 4 www.rcr.ac.uk administration to adult patients Recommended Standard 4 Standard 7 standards In cases where there is a previously GBCAs deemed to be high-risk in reported moderately severe or regard to their association with the Standard 1 severe reaction to intravascular development of nephrogenic An individual trained in recognising contrast, caution should be systemic fibrosis (NSF) are and treating severe contrast exercised and the need for the use contraindicated in patients with reactions, including anaphylaxis, of contrast should be re-examined severe chronic or acute renal should be immediately available in with respect to an unenhanced impairment, patients in the peri- the department where contrast is study or other potential methods of operative liver transplantation administered. investigation. period and in neonates. Standard 2 Standard 5 Standard 8 A formal record of the decision to For elective examinations in When using GBCAs, renal function inject intravascular contrast should patients who have a history of must be known for all patients be made before administration. previous contrast reaction, receiving agents deemed as high consideration should be given to risk. Knowledge of renal functional Standard 3 referral to a specialist drug allergy status is also generally advisable for service for assessment and testing patients receiving agents classed as The individual administering the against a panel of contrast medium risk. contrast must check that there are compounds to determine the safety no contraindications to its use and of administration. Standard 9 ensure that the patient understands Significant suspected contrast that it is to be given and agrees to Standard 6 the procedure. reactions should be formally The dose of non-ionic iodine-based documented with full details, contrast medium should be investigated appropriately with minimised, taking into advice given to the patient and consideration the indication and referral made to a specialist drug the patient’s body weight. allergy service to help guide future management. Standards for intravascular contrast Standards for intravascular contrast administration to adult patients administration to adult patients www.rcr.ac.uk 5 1. Introduction 2. General safety issues 3. Practical safety issues The use of intravascular contrast in Non-ionic, low or iso-osmolar An individual trained in recognising radiology continues to increase. iodinated media are five to ten and treating severe contrast The potential risks of intravascular times safer than the older, high reactions, including anaphylaxis, administration of contrast must be osmolar ionic contrasts.2 should be immediately available in weighed against the potential the department. This could be a Both low osmolar iodinated media benefits. Withholding contrast may registered nurse or radiographer or and GBCAs are associated with a deprive patients of the benefits of other appropriately trained very low rate of adverse events valuable diagnostic information or healthcare professional. (0.15% for low osmolar iodine necessary therapy. This document contrast and 0.04% for
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