Standards for intravascular contrast administration to ...

1 For intravascular contrast administration to adult patientsFaculty of Clinical RadiologyThird for intravascular contrast administration to adult patientsContentsForeword 3 Recommended Standards 41. Introduction 52. General safety issues 53. Practical safety issues 54. Prescribing contrast 65. Patient information and consent 66. Identifying patients at increased risk from contrast administration 77. Recommendations for contrast use in patients at increased risk 7 History of previous contrast reaction 7 Asthma 7 Multiple allergies or a documented severe allergy requiring therapy 8 Renal disease, diabetes mellitus and conditions associated with renal impairment 8 Risk factors for acute kidney injury in adults receiving iodinated contrast media 8 Metformin 98. Other special cases 9 Pregnancy 9 Lactation 9 Thyroid 9 Interleukin-2 treatment 99. Gadolinium contrast agents 10 Advice 10 Renal function monitoring 10 Renal impairment 10 Perioperative liver transplantation period 11 Breastfeeding 11 P r e g n a n c y 11 Haemodialysis 11 Recording of the agent used 1110.

2 The treatment of reactions 11 Nausea/vomiting 11 U r t i c a r ia 11 Bronchospasm 11 Laryngeal oedema 12 Hypotension 12 Generalised anaphylactic reaction 12 Recording and investigation of significant suspected contrast reactions 12 contrast medium extravasation 12 Delayed skin reactions 1311. Conclusion 13 References 14 Appendix 1. contrast -induced acute kidney injury 16 Appendix 2. Chronic kidney disease stages 17 Appendix 3. Clinical features and clinicopathological definition of NSF 18 Appendix 4. European Medicines Agency classification of gadolinium-based contrast agents 20 Appendix 5. Definitions of confounded and unconfounded cases of contrast reaction 21 RCR StandardsThe Royal College of Radiologists (RCR), a registered charity, exists to advance the science and practice of radiology and undertakes to produce Standards documents to provide guidance to radiologists and others involved in the delivery of radiological services with the aim of improving the service for the benefit of patients by defining best practice, and promoting advances in Standards documents cover a wide range of topics.

3 All have undergone an extensive consultation process to ensure a broad consensus, underpinned by published evidence where applicable. Each is subject to review four years after publication or earlier if RCR has committed to reviewing all relevant publications in line with the recommendations of the Francis report and, where appropriate, applying the category of standard defined by Francis (fundamental, enhanced or developmental).1 This document contains Standards that fall within the enhanced category. The Standards are not regulations governing practice but attempt to define the aspects of radiological services and care which promote the provision of a high-quality service to patients. All of the Standards produced by the RCR can be found on the College website classification of RCR Standards Fundamental Standards of minimum safety and quality in respect of which non-compliance should not be tolerated. Failures leading to death or serious harm should remain offences for which prosecution can be brought against organisations.

4 There should be a defined set of duties to maintain and operate an effective system to ensure compliance. Enhanced quality Standards : such Standards could set requirements higher than the fundamental Standards , but would be discretionary matters for commissioning and subject to availability of resources. Developmental Standards which set longer term goals for providers: these would focus on improvements in effectiveness and are more likely to be the focus of for intravascular contrast administration to adult for intravascular contrast administration to adult patientsForewordThese 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.

5 The RCR would also like to thank the members of the Professional Support and Standards Board (PSSB) who made significant 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 FitzGeraldVice-President, Clinical RadiologyThe Royal College of Radiologists Current Standards documents Standards for the provision of an ultrasound serviceStandards of practice of computed tomography coronary angiography (CTCA) in adult patientsCancer multidisciplinary team meetings Standards for clinical radiologists, Second editionStandards for Learning from Discrepancies meetings Standards for radiofrequency ablation (RFA), Second editionStandards for patient confidentiality and PACS and RISS tandards for the communication of critical, urgent and unexpected significant radiological findings, Second editionStandards for patient consent particular to radiology.

6 Second editionStandards of practice and guidance for trauma radiology in severely injured patientsStandards and recommendations for the reporting and interpretation of imaging investigations by non-radiologist medically qualified practitioners and teleradiologistsStandards for the NPSA and RCR safety checklist for radiological interventionsStandards for the provision of teleradiology within the United KingdomStandards for the recording of second opinions or reviews in radiology departmentsStandards for a results acknowledgement systemStandards for providing a 24-hour diagnostic radiology serviceStandards for providing a 24-hour interventional radiology serviceStandards for Self-assessment of PerformanceStandards for the Reporting and Interpretation of Imaging investigationsStandards for Ultrasound Equipment for intravascular contrast administration to adult patientsRecommended standardsStandard 1An individual trained in recognising and treating severe contrast reactions, including anaphylaxis, should be immediately available in the department where contrast is 2A formal record of the decision to inject intravascular contrast should be made before 3 The individual administering the contrast must check that there are no contraindications to its use and ensure that the patient understands that it is to be given and agrees to the 4In cases where there is a previously reported moderately severe or severe reaction to intravascular contrast , caution should be exercised and the need for the use of contrast should be re-examined with respect to an unenhanced study or other potential methods of investigation.

7 Standard 5 For elective examinations in patients who have a history of previous contrast reaction, consideration should be given to referral to a specialist drug allergy service for assessment and testing against a panel of contrast compounds to determine the safety of administration . Standard 6 The dose of non-ionic iodine-based contrast medium should be minimised, taking into consideration the indication and the patient s body 7 GBCAs deemed to be high-risk in regard to their association with the development of nephrogenic systemic fibrosis (NSF) are contraindicated in patients with severe chronic or acute renal impairment, patients in the peri-operative liver transplantation period and in 8 When using GBCAs, renal function must be known for all patients receiving agents deemed as high risk. Knowledge of renal functional status is also generally advisable for patients receiving agents classed as medium 9 Significant suspected contrast reactions should be formally documented with full details, investigated appropriately with advice given to the patient and referral made to a specialist drug allergy service to help guide future management.

8 For intravascular contrast administration to adult patientsStandards for intravascular contrast administration to adult patients1. Introduc tionThe use of intravascular contrast in radiology continues to increase. The potential risks of intravascular administration of contrast must be weighed against the potential benefits. Withholding contrast may deprive patients of the benefits of valuable diagnostic information or necessary therapy. This document aims to provide guidance on how intravascular contrast may be used as safely as possible. This document deals with administration of intravascular contrast to adult patients. For children and neonates, a paediatric radiologist should be consulted. 2. General safety issuesNon-ionic, low or iso-osmolar iodinated media are five to ten times safer than the older, high osmolar ionic low osmolar iodinated media and GBCAs are associated with a very low rate of adverse events ( for low osmolar iodine contrast and for gadolinium contrast ).

9 3 Most adverse events are mild and can be managed in the radiology major life-threatening contrast reaction is rare. The incidence of severe reactions with non-ionic contrast media is and very serious reactions is ,3 For GBCAs, the severe adverse reaction rate is even lower, estimated to be minimise risk, it is important to identify individuals at an increased risk of an adverse steps to reduce the risk of contrast reactions should always be Practical safety issuesAn individual trained in recognising and treating severe contrast reactions, including anaphylaxis, should be immediately available in the department. This could be a registered nurse or radiographer or other appropriately trained healthcare should be systems in place to call an appropriately trained doctor who can deal immediately with a severe contrast reaction. If required, this may include a crash the presence of risk factors, the decision about contrast administration should only be taken by the radiologist responsible for the procedure.

10 This decision process should include the location of the proposed examination with reference to resuscitation view of the risk of contrast nephrotoxicity, dehydration of patients before contrast administration is undesirable and should be avoided. Facilities for the treatment of acute adverse reactions should be readily available and regularly checked within the department. A patient should not be left alone or unsupervised in the first five minutes after an injection of any intravascular contrast . for intravascular contrast administration to adult patientsIt is advisable that the patient remains on the premises for at least 15 minutes following the injection. Most severe reactions occur during this time. In patients at increased risk of a reaction, this should be increased to 30 minutes. All contrast reactions, with details of their nature, severity and the specific compound used, should be included in the radiological report, updated in the patient s hospital notes and on the radiology information system (RIS).