Contrast Simulation Study material

1. ACR guidelines on Contrast
Reactions and Management
Z Liu, PGY-3
Boston University Medical Center, Department of Diagnostic Radiology
Last reviewed May 9, 2015

2. Disclaimer
• The information provided herein is designed to aid in the BMC contrast reaction
simulation course and may contain errors.
• All treatments listed herein are for ADULTS.
• DO NOT REFER TO THIS INFORMATION FOR ACTUAL PATIENT CARE
Thank you,
Your Radiology Simulation Team
May 9, 2015

3. INDEX
Abbreviations
1. IV contrast media types
2. Risk factors for contrast reactions
3. Contrast related adverse reactions (CIN, NSF, etc)
4. IV contrast and pregnant patients
5. IV contrast and breast feeding
6. Premedication and BMC regime
7. Acute contrast reactions and management (per ACR guidelines 2013)
8. Reaction rebound prevention
9. MR specific protocol
10. Miscellaneous (translator phone, update allergy on Epic)
References

4. Abbreviations
CIN Contrast-induced nephrotoxicity
NSF Nephrogenic Systemic Fibrosis
HOCM High-osmolality contrast media

5. IV contrast media types
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6. IV contrast
• Ionic:
• Higher osmolality
• More side effects
• Non-ionic:
• Lower osmolality (toxicity decreases as osmo approaches serum osmo)
• Bound to organic compound
• Fewer side effects (do not dissociate into component molecules)
• Examples:
• Isovue 370
• Optiray 320

7. MR IV contrast agents
 Gadolinium (Gd): Paramagnetic
 Most commonly used
 Chelated form- bind to an organic compound
 Extracellular fluid agents
 Ionic (Magnevist)
 Non ionic (Prohance)
 Blood pool agents
 Albumin-binding (Ablavar)
 Organ specific agent
 Eovist (liver)

8. Contrast reactions
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9. Symptoms
Type
Event
Acute contrast reaction
Anaphylactoid
Mild (skin rash, itching, nasal discharge,
nausea, vomiting)
Moderate (persistent mild symptoms,
facial/laryngeal edema, bronchospasm,
dyspnea, tachycardia, bradycardia)
Severe (life-threatening arrhythmia,
hypotension, overt bronchospasm, laryngeal
edema, pulmonary edema, seizure, syncope,
death)
Non-anaphylactoid
Vasovagal, warmth, metallic taste, nausea,
vomiting, bradycardia, hypotension,
neuropathy
Delayed reactions (Fever, chills, flushing,
pruritus, nausea, vomiting, headache)
Singh J 2008

10. Risk Factors for Adverse Reactions
to Intravenous Contrast Material
 History of a prior allergy-like reaction to contrast media is associated with an up
to five fold increased likelihood
 Allergic diathesis predisposes individuals to reactions
 Asthma may indicate an increased likelihood of a contrast reaction
 Anecdotal evidence that severe adverse effects to contrast media or to
procedures can be mitigated at least in part by reducing anxiety
 Renal insufficiency: CIN and NSF

11. Other risks
 Significant cardiac disease may be a risk factor for contrast reactions.
 These include symptomatic patients:
 patients with angina or congestive heart failure symptoms with minimal exertion
 patients with severe aortic stenosis, primary pulmonary hypertension, or severe but well-
compensated cardiomyopathy.
 Limit the volume and osmolality of the contrast media
 Paraproteinemias, particularly multiple myeloma, are known to predispose
patients to irreversible renal failure after high-osmolality contrast media (HOCM)
administration due to tubular protein precipitation and aggregation; however,
there is no data predicting risk with the use of low-osmolality or iso-osmolality
agents.
More on risk factors: ACR Manual on Contrast Media Version 9, 2013

12. Thyroid disease and IV contrast
 Some patients with hyperthyroidism or other thyroid disease (especially when
present in those who live in iodine-deficient areas) may develop iodine-provoked
delayed hyperthyroidism. This effect may appear 4 to 6 weeks after the IV contrast
administration in some of these patients.
 BMC Policy: [Pending policy update]

13. Sickle cell trait or disease
 Risk to sickle cell patients from IV administered GBCM at currently approved
dosages must be extremely low, and there is no reason to withhold these agents
from patients with sickle cell disease. However, as in all patients, GBCM should
be administered only when clinically indicated.

14. Metformin
 Metformin does not confer an increased risk of CIN. However, metformin can very
rarely lead to lactic acidosis in patients with renal failure. Therefore, patients who
develop CIN while taking metformin are susceptible to the development of lactic
acidosis
 BMC policy: [Pending policy update]

15. Neonates and infants
 In children, it is prudent to follow the same guidelines that apply to adults.
 It should be noted, however, that eGFR values in certain premature infants
and neonates may be < 30 ml/min/1.73 m2 simply due to immature renal
function (and not due to pathologic renal impairment).
 In these individuals, the ACR Committee on Drugs and Contrast Media
believes that caution should still be used when administering GBCAs,
although an eGFR value < 30 ml/min/1.73 m2 should not be considered an
absolute contraindication to GBCA administration.

16. Contrast related adverse reactions
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17. Mechanisms of anaphylactoid contrast reactions
 ~90% of such adverse reactions are associated with direct release of histamine
and other mediators from circulating basophils and eosinophils.
 Why use IV methylprednisone?
 Reduction in circulating basophils and eosinophils (which reach maximal statistical
significance at the end of 4 hours). A reduction of histamine in sedimented leukocytes
is also noted at 4 hours. Many of these effects reach their maximum at 8 hours.

18. Nephrogenic systemic fibrosis
 Fibrosing disease involving skin and subcutaneous tissues, also lungs,
esophagus, heart, skeletal muscles (contractures and joint immobility).
 Initial symptoms: skin thickening and or pruritis
 BMC policy: [Pending policy update]

19. Delayed reactions to contrast media
 Incidence: 0.5 to 14%.
 Most commonly cutaneous (urticarial and/or a persistent rash) and may develop
from 30 to 60 minutes to up to one week following contrast material exposure,
with the majority occurring between three hours and two days.
 Treatment: supportive, antihistamines and or corticosteroids for cutaneous
symptoms, antipyretics for fever, antiemetics for nausea, and fluid resuscitation
for hypotension.
 REMEMBER: Nearly all life-threatening contrast reactions occur within the first 20
minutes after contrast medium injection.

20. Contrast related reactions
 Air embolism
 Contrast induced nephrotoxicity
 Nephrogenic systemic fibrosis
 Delay reactions
 Acute contrast reactions (mild, moderate, severe/anaphylactic)

21. Air embolism
• Extremely rare complication
• Power injection minimizes risk
• Air bubbles or air fluid levels in the intrathoracic veins, main PA, or RV.
• Symptoms: air hunger, dyspnea, cough, chest pain, pulmonary edema,
tachycardia, hypotension, or expiratory wheezing. Neurologic deficits may result
from stroke due to decreased cardiac output or paradoxical air embolism.
• Treatment: 100% oxygen and placing the patient in the left lateral decubitus
position (i.e., left side down).

22. Contrast induced nephrotoxicity
• Pathophysiology: unclear but suggested etiologies include renal
hemodynamic changes (vasoconstriction) and direct tubular toxicity
• Absolute increase of Cr of 0.5 mg/dL.
• Risk factors: pre-existing renal insufficiency, acute kidney injury
• Other independent risk factors: diabetes mellitus, dehydration,
cardiovascular disease, diuretic use, advanced age, multiple myeloma,
hypertension, hyperuricemia, and multiple iodinated contrast medium
doses in a short time interval (< 24 hours)
• BMC policy: [Pending policy update]

23. IV contrast and pregnant patients
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24. IV contrast media and pregnant patients
 BMC policy: [Pending policy update]
 BMC policy: [Pending policy update]

25. IV contrast and breast feeding
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26. IV contrast media and breast feeding
 Plasma half life of IV contrast is ~ 2 hours
 Nearly 100% of contrast media is cleared renally within 24 hours given normal
renal function
 <1 % is excreted into breast milk in first 24 hours so it is safe for the mother and
infant to continue breast-feeding after receiving such an agent
 BMC policy: [Pending policy update]

27. Premedication and BMC regime
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28. Premedication
 No randomized controlled clinical trials have demonstrated premedication
protection against severe life-threatening adverse reactions.
 Target premedication to those whom, in the past, have had moderately severe or
severe reactions requiring treatment.
 Oral administration of steroids is preferable to IV administration, and prednisone
and methylprednisolone are equally effective. It is preferred that steroids be given
beginning at least 6 hours prior to the injection of contrast media regardless of the
route of steroid administration whenever possible.
 BMC policy: Pending policy update

29. BMC Premedication regime
Patients who are able to take medication orally:
 Prednisone 50mg tablet by mouth at 13 hours, 7 hours, and 1 hour before injection of
contrast media.
Or
 Methylprednisolone (Medrol®) 32mg tablet by mouth at 12 hours and 2 hours before
the injection of contrast media.
Plus
 Diphenhydramine (Benadryl®) 50mg intravenously, intramuscularly or by mouth 1 hour
before the injection of contrast media.

30. BMC Premedication regime
 Patients unable to take oral medication:
 Hydrocortisone: 200mg intravenously at 13 hours, 7 hours, and 1 hour before the
injection of contrast media.
 Plus
 Diphenhydramine 50mg intravenously or intramuscularly 1 hour before the injection of
contrast media.

31. BMC Premedication regime
 Emergent or Urgent patients:
 Dexamathasone (Decadron) 4-8 mg intravenously.
 Plus
 Diphenhydramine (Benadryl®) 25mg intravenously.
 Wait 15 minutes and scan.

32. Contrast reactions & management
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33. Assessing for potential contrast reaction
 How does the patient look?
 Can the patient speak? How does the patient’s voice sound?
 How is the patient’s breathing?
 What is the patient’s pulse strength and rate?
 What is the patient’s blood pressure?

34. Acute adverse reactions
• May be allergic-like (not true allergy, often idiosyncratic and may differ
immunologically from true allergies despite similar clinical presentations) or
physiologic (a physiologic response to contrast material).
• Mild
• Moderate
• Severe

35. Allergy
Anaphylaxis
 Severe
 Rapid onset
 IgE mediated (prior sensitization)
 Non dose dependent
Anaphylactoid
 Less severe
 Slower onset
 Mast cell cascade (NOT IgE)
 Dose dependent

36. Range of allergic reactions

37. MILD

38. MODERATE

39. SEVERE

40. Severe
 Cardiopulmonary arrest
 Pulmonary edema: rare

41. HIVES-GENERAL
 Observe patient until hives are resolving.
 Further observation may be necessary if treatment is administered.
 BMC policy: [Pending policy update]

42. HIVES-MILD
*Note: All forms can cause drowsiness; IV/IM form may cause or worsen hypotension.
** Note: second generation antihistamines cause less drowsiness; may be beneficial in patients that need to drive themselves home.

43. HIVES-MODERATE
*Note: All forms can cause drowsiness; IV/IM form may cause or worsen hypotension.
** Note: second generation antihistamines cause less drowsiness; may be beneficial in patients that need to drive themselves home.

44. HIVES-SEVERE
* ALL FORMS CAN CAUSE DROWSINESS; IM/IV FORM MAY CAUSE OR WORSEN HYPOTENSION

45. DIFFUSE ERYTHEMA
 Preserve IV access
 Monitor vitals
 Pulse ox
 Give O2 by mask (6-10L/min) in all patients
 If normotensive: no additional treatment

46. DIFFUSE ERYTHEMA-HYPOTENSIVE
* Note: in hypotensive patients, the preferred route of epinephrine delivery is IV, as the extremities may not be perfused sufficiently to
allow for adequate absorption of IM administered drug

47. Bronchospasm
• Preserve IV access
• Monitor vitals
• Pulse ox
• Give O2 by mask (6-10L/min) in all patients

48. BRONCHOSPASM-MILD

49. BRONCHOSPASM-MODERATE

50. BRONCHOSPASM-SEVERE

51. Laryngeal Edema
• Preserve IV access
• Monitor vitals
• Pulse ox
• Give O2 by mask (6-10L/min) in all patients

52. LARYNGEAL EDEMA

53. Hypotension
 Systolic BP < 90 mm Hg
 Two forms:
 Hypotension with bradycardia
 Hypotension with tachycardia

54. Hypotension
 Preserve IV access
 Monitor vitals
 Pulse ox
 Give O2 by mask (6-10L/min) in all patients
 Elevate legs at least 60 degrees
 Consider IV fluids: 0.9% Normal Saline or Latcted Ringers, 1,000 mL rapidly

55. HYPOTENSION WITH BRADYCARDIA (HR<60)
“VASOVAGAL REACTION”

56. (HR>100)
“ANAPHYLACTOID REACTION”

57. UNRESPONSIVE AND PULSELESS
• Apply BLS, ACLS
• Activate emergency response team
• If at Menino or ENC, call 4-7777
• If at Shapiro, call public safety 4-4444 (they will call 911)

58. HYPERTENSIVE CRISIS
BP>200/120, SYMPTOMS OF END ORGAN COMPROMISE
•Preserve IV access
•Monitor vitals
•Pulse ox
•Give O2 by mask (6-10L/min) in all patients
•Labetalol (IV): 20 mg IV slowly over 2 min
OR
•Nitroglycerine tablet (SL): 0.4 mg tablet; can repeat every 5–10 min
•Furosemide (lasix): 20-40 mg IV slowly over 2 min

59. PULMONARY EDEMA
• Activate emergency response team
(4-7777 at Menino or ENC; 4-4444 at Shapiro (public safety will
call 911)
• Preserve IV access
• Monitor vitals
• Pulse ox
• Give O2 by mask (6-10L/min) in all patients
• Elevate head of bed, if possible
• Furosemide (lasix): 20-40 mg IV slowly over 2 min
• Morphine (IV): 1-3 mg, repeat every 5-10 min as needed

60. SEIZURES/CONVULSIONS
 Observe and protect the patient (turn patient on side to avoid aspiration)
 Suction airway, as needed
 Preserve IV access
 Monitor vitals
 Pulse oximeter
 O2 by mask (6-10 L/min)
 If unremitting:
 Call a code or 911
 Give Lorazepam* (IV) IV 2–4 mg IV; administer slowly, to maximum dose of 4 mg
*Ativan®

61. Observation period
 In those patients whose allergic reaction is not severe and can be monitored in
the recovery area, ACR guideline recommends observing the patient until
patient’s symptoms completely resolve
 BMC protocol: Observe for 30 minutes or until symptoms resolve.
 Give patients clear instructions to seek additional medical care, should there be
any worsening of symptoms, skin ulceration, or development of any neurologic or
circulatory symptoms including paresthesias.

62. MR specific protocol
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63. MR specific protocol
 Leave all metal objects at Zone II or III including cell phones, credit cards, etc.
 Must first transfer patient (in Zone IV) to Zone II (outside magnet area) on MRI
compatible stretcher before any further assessment and treatment.
 Zone I: All areas freely accessible to the general public without supervision.
Magnetic fringe fields in this area are less than 5 Gauss (0.5 mT).
 Zone II: Still a public area, but the interface between unregulated Zone I and the
strictly controlled Zones III and IV. MR safety screening typically occurs here.
 Zone III: An area near the magnet room where the fringe, gradient, or RF magnetic
fields are sufficiently strong to present a physical hazard to unscreened patients
and personnel.
 Zone IV: Synonymous with the MR magnet room itself.

64. Miscellaneous
(translator phone, update allergies on Epic)
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65. How to call a code
 At Menino and ENC: 4-7777
 At Shapiro: Call 4-4444 (public safety will call 911)
 Know relevant information when calling a code (Name, adult vs child, location,
type of contrast event, what happened, any pertinent medical history).

66. How to use the translator phone
 If using the blue phone-press on the pre-programmed blue button or dial 7-8787
to get a translator. Will ask for language, department you are calling from, and
patient’s MRN.
 If using a white phone, dial 7-6767. Follow the same steps as above.
 If using a red phone (in house translator), directly asks for an available in house
translator (might have to wait).

67. Updating allergic reaction on Epic
Click on the allergies tab on the left hand side, click on add a new agent, a
drop down menu will appear and you can add the new agent and the
associated reactions.
New contrast allergies can be updated by contacting CT manager Christine
Seay.

68. References
 ACR Manual on contrast media 2013 version 9
 BMC Adverse reactions to contrast media and contrast extravasations
 BMC recommendation for serum creatinine for contrast administration
 BMC Guidelines for management of acute contrast reactions in adults
 BMC Contrast media allergy prophylactic medication regimens
 BMC contrast media and the pregnant patient
 Singh J, Daftary A. Iodinated contrast media and their adverse reactions. J Nucl Med Technol.
2008 Jun;36(2):69-74; quiz 76-7. doi: 10.2967/jnmt.107.047621. Epub 2008 May 15. Review.
PubMed PMID: 18483141.
 http://mri-q.com/acr-safety-zones.html
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