Mothers who are breastfeeding should abstain from breastfeeding after receiving IV contrast medium for a period of 24hours. Active expression and discarding of breast milk from both breasts during that period is recommended.

BUN

See Dehydration

Central Venous Catheter Policy

Central venous catheters including PICC lines may not be used with a power injector. Most catheters are currently rated from 15-40psi which is far below the PSI needed for current CT scan protocols. Bard PowerPICC is the only CVC currently rated for power injection (up to 300 psi).

Congestive Heart Failure

Patients with congestive heart failure must be given Visipaque. Contrast could trigger pulmonary edema in these patients. Hydration may not be recommended so careful consultation with the referring physician is recommended if the Creatinine falls into the top normal range.

Contraindications for IV Contrast

Asthma

Previous moderate or severe reaction to IV contrast

Severe allergic reaction to food or medication requiring hospitalization

Multiple Myeloma

Pheochromocytoma

Sickle Cell Disease

Renal Insufficiency

Metformin (Glucophage)

Pregnancy

Diabetics

Patients should be managed the following way:

§ current creatinine (within 14 days) must be available

§ correlate results with the renal function protocol

§ If within normal range-ok to inject

§ If in top normal range (.1-.5 greater normal for sex and age group) –

Prescribe Mucomyst 20% solutuion (200 mg./cc) 3cc. orally BID the day prior to and the day of the study.

§ Inject with Visipaque.

§ Follow up creatinine and hydration instructions

Dehydration (Increased BUN)

Patients with significant increases in BUN level need to be managed post contrast injection with adequate hydration.

Dialysis

See Hemodialysis

Extravasation Treatment

· Stop the injection immediately

· Remove the catheter and place gauze on the area. Gently massage for a few minutes.

· Notify Radiologist for extravasations over 20cc. After hours, notify ER attending or attending Physician.

· Elevate extremity.

· Place ice pack.

· Observe patient in the department for 30 minutes after the study.

· Give printed directions to Outpatients. Attach printed instructions to front of IP charts. Tech should speak to patient’s nurse.

· Fill out incident report.

· Document rate, size of IV, location, and approximate amount infiltrated.

Extravasation over 20cc requires follow-up.

Forward Incident report to supervisor or next shift for 24hour follow up with the patient at their home or with their nurse if they are an Inpatient.

Document findings on the incident report. If no improvement, a Radiologist should speak to the attending physician for the patient.

Glucophage/Glucovance

See Metformin Policy

Hemodialysis/

Continuous ambulatory peritoneal dialysis

Extra hemodialysis sessions for removal of contrast media are unnecessary.

Correlation of the time of contrast injection with hemodialysis sessions is unnecessary.

Injection Procedure

· Using sterile technique, draw contrast into syringe using transfer device

· Prime line to expel all air from syringe and tubing.

· Tilt injector head down toward the floor.

· Connect tubing to angiocatheter or existing line

· Alcohol swab any existing port adapter before connecting contrast.

· Flush line with 10cc saline to test patentcy.

· Monitor site during pre scan delay for extravasation

· Keep arm straight as possible during the injection.

· Do not administer contrast with concurrent chemo or blood infusions since it is difficult to determine which product caused reaction.

Isotope Imaging of the Thyroid

Isotope imaging of the thyroid should be avoided for two months after iodinated IV contrast medium injection.

Kidney

One Kidney

Patients should be managed the following way:

§ current creatinine (within 14 days) must be available

§ correlate results with the renal function protocol.

§ If within normal range-ok to inject

§ Visipaque 320 must be used. 100 cc

Transplant Kidney

IV contrast should only be given to patients with a transplanted kidney if absolutely necessary.

Patients should be managed the following way:

§ current creatinine (within 14 days) must be available

§ correlate results with the renal function protocol.

§ If within normal range-ok to inject

§ Visipaque 320 must be used. 100cc

Medical Renal Disease

Patients should be managed the following way:

§ current creatinine (within 14 days) must be available

§ correlate results with the renal function protocol

§ If within normal range-ok to inject

§ If in top normal range (.1-.5 greater normal for sex and age group) –

Prescribe Mucomyst 20% solutuion (200 mg./cc) 3cc. orally BID the day prior to and the day of the study.

§ Inject with Visipaque.

§ Follow up creatinine and hydration instructions

Metformin

(Oral Hypoglycemic drugs containing Metformin)

(Advandamet, Metaglip, Glucovance, Glucophage)

There is no interaction between Metformin and IV Contrast.

If patient develops renal failure acutely because of the contrast, toxic levels of Metformin can accumulate and result in a lethal lactic acidosis.

Patients should be managed the following way:

§ current creatinine (within 14 days) must be available

§ correlate results with the renal function protocol

§ If within normal range-ok to inject

§ If in top normal range (.1-.5 greater normal for sex and age group) – Prescribe Mucomyst 20% solutuion (200 mg./cc) 3cc. orally BID the day prior to and the day of the study.

§ Inject with Visipaque.

§ Follow up creatinine and hydration instructions should be given to the patient or caregiver.

§ Patient should stop taking the medication for 48hours post injection.

§ At 48hours a creatinine should be drawn to determine status of renal function.

§ When results are found to be in normal range, the patient can resume taking this medication.

§ OP should be given written instruction sheet. IP will have orders to D/C metformin and obtain labwork at 48hours

Outpatients will be given the following written instructions to give to their physician.

Patient Instructions

Glucophage

Glucovance

Avandamet,Metaglip

(Metformin)

The medication which you are taking for your Diabetes, should be stopped

after this test for 48 hours.

You should inform the Physician that requested this exam, immediately,

that you will need to have lab work drawn in order to evaluate your renal

function at 48 hours. The labwork needed is BUN level and Creatinine level.

Your doctor should inform you of the results of this labwork and ask you to

resume taking this medication after the results are found to be normal.

If your doctor has any questions or concerns, please tell him to contact

the Radiology Department and speak to a Radiologist.

(Metformin Policy –continued)

Inpatients-The following instructions will be written in the nursing notes on the patient’s chart.

1) D/C _______________________________

2) Obtain Creatinine in 48 hours

3) If Creatinine is normal or has not risen since prior to

receiving IV contrast, then resume_________________

Multiple Myeloma

Patients with known history of Multiple Myeloma should not receive IV contrast medium.

These patients are high risk to develop renal insufficiency after contrast administration.

Nephrotoxic drugs (Gentamycin and nSAIDS)

Patients should be managed the following way:

§ current creatinine (within 14 days) must be available

§ correlate results with the renal function protocol

§ If within normal range-ok to inject

§ If in top normal range (.1-.5 greater normal for sex and age group) –

Prescribe Mucomyst 20% solutuion (200 mg./cc) 3cc. orally BID the day prior to and the day of the study.

§ Inject with Visipaque.

§ Follow up creatinine and hydration instructions should be given to the patient or caregiver.

Pediatric Dosing

1cc/ pound

Peritoneal Dialysis

See Hemodialysis

Pheochromocytoma

Patients with known history of Pheochromocytoma should not receive IV contrast.

Administration of contrast could potentially trigger a hypertensive crisis.

Pregnancy

§ IV contrast has not been widely studied on effects to the unborn fetus.

§ IV contrast is contraindicated in pregnant females unless there is HIGH suspicion of PE which would be life threatening to the mother.

§ Visipaque should be used.

Premedication Protocol

32 mg Methylprednisolone (Medrol) po 12hours prior to exam

32 mg Methylprednisolone po 2 hours prior to exam

(Note: commonly dispensed in 16mg tabs)

Emergent Premedication

6mg Decadron IV 1hour prior to exam

Preparation of Contrast

It is recommended that contrast is warmed to body temperature (98.7 degrees)

Warming IV contrast decreases the viscosity of the iodine solution.

This is important with high rate injections and when using higher concentrations of contrast medium such as 350 or greater.

Prior reaction to IV contrast

Patients who have had a prior reaction to IV contrast must be pre-medicated before IV contrast is administered.

Patients with prior history of anaphylactic reaction should not be given IV Contrast.

Renal Transplant

See Kidney

Renal Function Protocol (IV Contrast Renal Function Guidelines)

All patients with a history of one or more of the following must have a creatinine drawn within two weeks prior to a study requiring intravenous contrast media.

o Medical Renal Disease

o Diabetes

o Difficulty Voiding

o Congestive Heart Failure

o Dehydration

o Taking nephrotoxic drugs (i.e. Gentamycin and NSAID’s)

If the creatinine obtained is:

Men ages 20 to 60 ----------------------- < 1.6
Men ages 61 and older ----------------- < 1.2
Women ages 20 to 60 ------------------- < 1.2
Woman ages 61 and older ------------- < 1

then the patient will receive non-ionic contrast and the study can be scheduled in the standard fashion.

If the creatinine is from 0.1 to 0.5 greater than the above normal, then IV contrast should only be given to answer the clinical question.

If IV contrast is required, then:

§ Patient will receive iso-osmolar IV contrast (Visipaque).

§ Patients with an IV should be hydrated, if not contraindicated, with IV normal saline at 100 cc./hour for 4 hours before and for 24 hours after IV contrast administration.

§ Patients without an IV should be encouraged to drink plenty of fluids up to 3 hours prior to receiving IV contrast.

§ Prescribe Mucomyst 20% solutuion (200 mg./cc) 3cc. orally BID the day prior to and the day of the study.

If the creatinine is > 0.5 above normal, then IV contrast should not be given unless the patient is on dialysis.

If serial creatinines are available, then determine if there has been a significant recent rise. Even though the last creatinine may be normal, a doubling in 24 hours indicates severe loss of renal function. Precautions should be taken and the procedure for elevated creatinine should be followed.

Emergency patients that cannot provide a history and/or must receive contrast before a creatinine can be obtained should receive Visipaque 320 or similar iso-osmolar contrast agent followed by hydration, as described above.

Referring Physicians must provide a copy of the creatinine results to their patients and instruct them to bring the results on the day of the IV contrast testing.

Post Procedure Care

All patients who receive IV contrast media despite an elevated creatinine should have a creatinine drawn 48 to 72 hours after contrast injection. The ordering physician should provide the patient with instructions and a prescription for the 48 to 72 hour creatinine.

Seafood Allergy/Shellfish Allergy

Patients with a history of allergy to shellfish or seafood may have IV contrast.

The concern would be if the patient had a severe reaction that caused them to go to the hospital, then it would be recommended that the patient be Pre-Medicated for the exam.

Sickle Cell Disease

Patients in acute crisis should not receive IV contrast.

Administration of contrast increases the risk of RBC sickling.

Patients with Sickle Cell Trait- may receive IV contrast if Creatinine is normal.

Thyroid

see Isotope imaging of thyroid

Treatment of Contrast Reactions

Contrast Reaction typically begins within 20 minutes of the injection.

Mild Symptoms

Scattered urticaria; pruritus; rhinorrhea; nausea; brief retching, and/or vomiting;diaphoresis;coughing; and dizziness.

FOR MILD TO MODERATE URTICARIA, PRURITIS, OR ERYTHEMA:

No therapy needed in most cases

Benadryl, 50mg or 1mg/kg p.o./i.m./I.V.

Watch for 30 minutes

Have someone drive the patient home

FOR SEVERE URTICARIA, PRURITIS, OR ERYTHEMA:

Epinephrine, 1:1000, 0.3 ml SQ (subcutaneously), or 0.01ml/kg, if there is no cardiac contraindication

FOR FACIAL OR LARYNGEAL EDEMA, OR STRIDOR:

Oxygen

Epinephrine, 1:1,000, 0.3ml SQ (0.01 ml/kg)

§ if SQ epinephrine fails or if patient experiences vascular collapse then give:

epinephrine, 1:10,000, 3ml I.V. slow push

FOR BRONCHOSPASM OR WHEEZING:

Oxygen, pulse oximeter (severe, <88%)

Bronchodilator nebulized in NS 2.5ml, such as:

Ø Isoetharine, 1% (Bronkosol), 0.25 to 0.5ml

Ø Albuterol, 0.5% (Ventolin, Proventil), 0.5ml

Ø Metaproterenol, 5% (Alupent, Metaprel), 0.3ml

¨ If no improvement:

§ Epinephrine, 1:1,000, 0.3 ml SQ (0.01 ml/kg)

Ø If SQ fails or if patient experiences vasular collapse then give: Epinephrine, 1:10,000, 3ml IV slow push

FOR HYPOTENSION WITH TACHYCARDIA, OR SHOCK:

Oxygen,Trendelenberg

Lactated Ringers Solution, I.V. wide open

¨ If no improvement:

§ Epinephrine, 1:1,000, 0.3 ml SQ (0.01 ml/kg)

¨ If SQ fails or vascular collapse:

§ Epinephrine, 1:10,000, 3ml I.V. slow push

HYPOTENSION WITH BRADYCARDIA (VAGAL REACTION)- no B Blocker:

Oxygen, Trendelenberg

Lactated Ringers I.V. wide open

¨ If no improvement:

§ Atropine, 0.5 to 1.0 mg I.V. slow push, repeat up to 2.0mg total