Patient selection and preparation strategies

ACR Manual on Contrast Media

ACR Manual on Contrast Media – Version 10.3 / May 31, 2017 Table of Contents / i

ACR Manual on Contrast Media

1. Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .V10 – 2015 . . . . . 3 2. Version History . . . . . . . . . . . . . . . . . . . . . . . . . . . . .V10.3 – 2017 . . . . 4 3. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V7 – 2010 . . . . . 5 4. Patient Selection and Preparation Strategies Before Contrast
Medium Administration . . . . . . . . . . . . . . . . . . . . . . . . V10.3 – 2017 . . . 6 5. Injection Of Contrast Media. . . . . . . . . . . . . . . . . . . . . . .V10.2 – 2016 . . . 16 6. Extravasation Of Contrast Media . . . . . . . . . . . . . . . . . . . V7 – 2010 . . . . 20 7. Allergic-Like And Physiologic Reactions To Intravascular
Iodinated Contrast Media . . . . . . . . . . . . . . . . . . . . . . . . . . . V9 – 2013 . . . . . 24 8. Contrast Media Warming . . . . . . . . . . . . . . . . . . . . . . . .V8 – 2012 . . . . . 31 9. Post-Contrast Acute Kidney Injury And Contrast-Induced
Nephropathy In Adults. . . . . . . . . . . . . . . . . . . . . . . . . .V10 – 2014 . . . . 35 10. Metformin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .V10.2 – 2016 . . . 47 11. Contrast Media In Children . . . . . . . . . . . . . . . . . . . . . . .V10 – 2014 . . . . 50 12. Gastrointestinal (GI) Contrast Media In Adults: Indications
And Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . .V9 – 2013 . . . . . 58 13. ACR–ASNR Position Statement On The Use Of Gadolinium
Contrast Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . .V10.2 – 2016 . . . 78 14. Adverse Reactions To Gadolinium-Based Contrast Media . . . . . . .V10 – 2014 . . . . 80 15. Nephrogenic Systemic Fibrosis . . . . . . . . . . . . . . . . . . . . .V10.3 – 2017 . . . 84 16. Ultrasound Contrast Media . . . . . . . . . . . . . . . . . . . . . . .V10.3 – 2017 . . . 93 17. Treatment Of Contrast Reactions . . . . . . . . . . . . . . . . . . . .V9 – 2013 . . . . . 96 18. Administration Of Contrast Media To Pregnant Or Potentially
Pregnant Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . .V10.3 – 2017 . . . 98 19. Administration Of Contrast Media To Women Who Are Breast-Feeding . . V9 – 2013 . . . . . .102 Table 1 – Categories Of Acute Reactions . . . . . . . . . . . . . . . . . .V10.2 – 2016 . . .104 Table 2 – Treatment Of Acute Reactions To Contrast Media In Children . .V10.2 – 2016 . . .106 Table 3 – Management Of Acute Reactions To Contrast Media In Adults. .V10.2 – 2016 . . . 114 Table 4 – Equipment For Contrast Reaction Kits In Radiology . . . . . . .V10.2 – 2016 . . .122 Appendix A – Contrast Media Specifications. . . . . . . . . . . . . . . . .V10 – 2014 . . . .123

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 are:

Laurence Needleman, MD, FACR Jeffrey H. Newhouse, MD, FACR Jay K. Pahade, MD
Carolyn L. Wang, MD
Jeffrey C. Weinreb, MD, FACR Stefanie Weinstein, MD

Finally, the committee wishes to recognize the efforts of supporting members of the ACR staff.

The following changes have been made:

Introduction

1. Assessment of patient risk versus potential benefit of the contrast assisted examination.

2. Imaging alternatives that would provide the same or better diagnostic information.

Patient Selection and Preparation Strategies Before Contrast Medium Administration

General Considerations

Allergic-like reactions to modern iodinated and gadolinium-based contrast medium are uncommon (iodinated: 0.6% aggregate [1], 0.04% severe [2]; gadolinium-based: 0.01-0.22% aggregate [3], 0.008% severe) [3,4]. Risk factors exist that increase the risk of a contrast reaction. These generally increase the likelihood of a reaction by less than one order of magnitude, effectively increasing the risk that an uncommon event will occur, but not guaranteeing a reaction will take place. The following are some examples:

Allergy: Patients who have had a prior allergic-like reaction or unknown-type reaction (i.e., a reaction of unknown manifestation) to contrast medium have an approximately 5-fold increased risk of developing a future allergic-like reaction if exposed to the same class of contrast medium again [3]. A prior allergic-like or unknown type reaction to the same class of contrast medium is considered the greatest risk factor for predicting future adverse events.

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ACR Manual on Contrast Media – Version 10.3 / May 31, 2017

Age and Gender: Infants, neonates, children, and the elderly have lower reaction rates than middle-aged patients [1,9]. Male patients have lower reaction rates than female patients. Due to the modest increased risk, restricting contrast medium use or premedicating solely on the basis of patient age or gender is not recommended.

Beta-Blockers: Some have suggested that use of beta-blockers lowers the threshold for contrast reactions, increases the severity of contrast reactions, and reduces the responsiveness of treatment with epinephrine [10]. Due to the modest increased risk, restricting contrast medium use or premedicating solely on the basis of beta-blocker use is not recommended. Patients on beta-blocker therapy do not need to discontinue their medication(s) prior to contrast medium administration.

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Hyperthyroidism: Patients with a history of hyperthyroidism can develop thyrotoxicosis after exposure to iodinated contrast medium, but this complication is rare [15]. Therefore, restricting contrast medium use or premedicating solely on the basis of a history of hyperthyroidism is not recommended. However, two special situations may affect this:

Pretesting

Intradermal skin testing with contrast media to predict the likelihood of adverse reactions has not been shown to be useful in minimizing reaction risk [19-21].

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ACR Manual on Contrast Media – Version 10.3 / May 31, 2017

Both of these randomized trials of premedication did not study the effect of premedication in high-risk patients who are usually premedicated today, and neither study was sufficiently powered to evaluate the efficacy of premedication in the prevention of moderate or severe reactions [22,27].

Nonetheless, many experts believe that premedication does reduce the likelihood of a reaction in high-risk patients receiving low-osmolality iodinated contrast medium [28], although the number needed to treat to prevent a reaction is high [29,30]. One study estimated that the number needed to premedicate to prevent one reaction in high-risk patients was 69 for a reaction of any severity and 569 for a severe reaction [29]. Another study estimated the number needed to treat to prevent a lethal reaction in high-risk patients to be 50,000 [30].

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Breakthrough Contrast Reactions: Premedication does not prevent all contrast reactions [29,34,35]. Allergic-like contrast reactions that occur despite premedication are called “breakthrough reactions” [34]. Physiologic reactions are not mitigated by premedication and are not considered “breakthrough reactions,” even if they occur following premedication.

The minimum duration of premedication necessary for efficacy is unknown. Lasser et al [27] showed that one dose of 32 mg oral methylprednisolone 2 hours prior to IV high-osmolality iodinated contrast medium administration in average-risk patients was not effective, while two doses administered at 2- and 12-hours before contrast medium administration were effective [27].

A dose-response study of single-dose IV methylprednisolone (1 mg/kg) [38] in 11 volunteers showed a reduction in circulating basophils and eosinophils by the end of the first post-injection hour, reaching statistical significance compared with controls by the end of the second hour and a concomitant reduction in histamine in sedimented leukocytes by 4 hours. Most of these effects reached their peak at 8 hours.

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ACR Manual on Contrast Media – Version 10.3 / May 31, 2017

Accelerated IV premedication may be considered in the following settings:

1. Outpatient with a prior allergic-like or unknown-type contrast reaction to the same class of contrast medium (e.g., iodinated – iodinated) who has arrived for a contrast-enhanced examination but has not been premedicated and whose examination cannot be easily rescheduled.

Specific Recommended Premedication Regimens

Elective Premedication (12- or 13-hour oral premedication)

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Although never formally compared, both regimens are considered similarly effective. The presence of diphenhydramine in regimen 1 and not in regimen 2 is historical and not evidence-based. Therefore, diphenhydramine may be considered optional.

3. Methylprednisolone sodium succinate (e.g., Solu-Medrol®) 40 mg IV or hydrocortisone sodium succinate (e.g., Solu-Cortef®) 200 mg IV, plus diphenhydramine 50 mg IV, each 1 hour before contrast medium administration. This regimen, and all other regimens with a duration less than 4-5 hours, has no evidence of efficacy. It may be considered in emergent situations when there are no alternatives.

Note: Premedication regimens less than 4-5 hours in duration (oral or IV) have not been shown to

In patients who have had a prior allergic-like reaction to contrast medium and who are also on chronic corticosteroid therapy, premedication dosing may be modified. In this circumstance, there is no evidence base to guide decision-making, so management should be individualized. Generally speaking, if corticosteroid premedication is being used, a guiding principle is to reduce the dose of the chosen premedication dose regimen by an amount equivalent to the patient’s chronic therapeutic corticosteroid dose. If the patient is on simple replacement (not therapeutic) corticosteroids, the premedication dosing regimen may not need to be adjusted.

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No premedication strategy is a substitute for pre-administration preparedness. Contrast reactions occur despite premedication [34], and radiology teams must be prepared to treat breakthrough reactions when they occur. Patients should receive information concerning their risk of a reaction according to local policy and practice.

References

5. Beaty AD, Lieberman PL, Slavin RG. Seafood allergy and radiocontrast media: are physicians propagating a myth? Am J Med 2008; 121 (2):158 e1-4, PMID: 18261505.

6. Boehm I. Seafood allergy and radiocontrast media: are physicians propagating a myth? Am J Med 2008; 121 (8):e19, PMID: 18691465.

11. Morcos SK. Review article: Acute serious and fatal reactions to contrast media: our current understanding. Br J Radiol 2005; 78 (932):686-93, PMID: 16046418.

12. Mukherjee JJ, Peppercorn PD, Reznek RH, Patel V, Kaltsas G, Besser M, Grossman AB. Pheochromocytoma: effect of nonionic contrast medium in CT on circulating catecholamine levels. Radiology 1997; 202 (1):227-31, PMID: 8988215.

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16. , 2017.

21. Yamaguchi K, Katayama H, Takashima T, Kozuka T, Seez P, Matsuura K. Prediction of severe adverse reactions to ionic and nonionic contrast media in Japan: evaluation of pretesting. A report from the Japanese Committee on the Safety of Contrast Media. Radiology 1991; 178 (2):363-7, PMID: 1987594.

22. Lasser EC, Berry CC, Talner LB, Santini LC, Lang EK, Gerber FH, Stolberg HO. Pretreatment with corticosteroids to alleviate reactions to intravenous contrast material. N Engl J Med 1987; 317 (14):845-9, PMID: 3627208.

27. O’Malley RB, Cohan RH, Ellis JH, Caoili EM, Davenport MS, Dillman JR, Khalatbari S, Myles JD. A survey on the use of premedication prior to iodinated and gadolinium-based contrast material administration. J Am Coll Radiol 2011; 8 (5):345-54, PMID: 21531312.

28. O’Malley RB, Cohan RH, Ellis JH, Caoili EM, Davenport MS, Dillman JR, Khalatbari S, Myles JD. A survey on the use of premedication prior to iodinated and gadolinium-based contrast material administration. J Am Coll Radiol 2011; 8 (5):345-54, PMID: 21531312.

33. Davenport MS, Cohan RH, Khalatbari S, Myles J, Caoili EM, Ellis JH. Hyperglycemia in hospitalized patients receiving corticosteroid premedication before the administration of radiologic contrast medium. Acad Radiol 2011; 18 (3):384-90, PMID: 21215661.

34. Freed KS, Leder RA, Alexander C, DeLong DM, Kliewer MA. Breakthrough adverse reactions to low-osmolar contrast media after steroid premedication. AJR Am J Roentgenol 2001; 176 (6):1389-92, PMID: 11373198.

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ACR Manual on Contrast Media – Version 10.3 / May 31, 2017

ACR Manual on Contrast Media – Version 10.3 / May 31, 2017

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Mechanical Injection of Intravenous Contrast Media

Bolus or power injection of IV contrast material is superior to drip infusion for enhancing normal and abnormal structures during body computed tomography (CT). Radiology personnel must recognize the need for proper technique to avoid the potentially serious complications of contrast media extravasation and air embolism. (See the Chapter on Extravasation of Contrast Media.) When the proper technique is used, contrast medium can be safely administered intravenously by power injector, even at high-flow rates.

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ACR Manual on Contrast Media – Version 10.3 / May 31, 2017