Management of acute Contrast Reactions

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Management of acute Contrast Reactions

• Fabio Komlos

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Outline

• Management of acute contrast reactions
• Management of IV infiltrations
• Special contrast related situations that may come
  up on call
• Metformin
• Pregnancy
• Dialysis
• Pheocromocytoma

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Catergories of reactions
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Risk factors for a reaction
Incidence of recurrence is LOW 8-25

• Prior reaction is best predictor.
• Shellfish allergy NOT a risk factor
• Multiple other allergies may increase risk but
  not a contraindication
• Asthma may increase risk of bronchospasm these
  patients may already have an inhaler with them.
• If reaction was minor and patient can tolerate
  hives, prob OK to proceed with a necessary scan.
• Bettmann, MA, Heeren T, GreenfieldA, Goudy C.
  Adverse events with radiographic contrast agents
  results of SCVIR Contrast Agent Registry.
  Radiology 1997 203 611-620

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Risk for Reaction
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Premedication

• Pre-medication with steroids and anti-histamines
• Only reduces incidence of minor reactions
• Must begin 12 hours prior to contrast injection
• Carries little negative consequences

Prednisone 40mg po 16, 8 and 2hr prior Benadryl
50mg po 2hr prior Ranitidine 150mg po 2h prio
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General approach to reactionsTechs

• 1 - Call radiology on call
• 2 - Call Radiology nurse
• Consider calling code

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General approach to reactionsRadiology Resident

• 1 - ABC (CPR)

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General approach to reactionsRadiology Resident

• 1 - ABC (CPR)
• 2 - Assessment
• O2
• Monitor (BP, pulse) consider cardiac
  monitor, pulse ox
• Access (assure venous access)

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General approach to reactionsRadiology Resident

• 1 - ABC (CPR)
• 2 - Assessment
• O2
• Monitor (BP, pulse) consider cardiac
  monitor, pulse ox
• Access (assure venous access)
• 3 Non-pharmacological measures
• Leg elevation
• Fluids

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General approach to reactionsRadiology Resident

• 1 - ABC (CPR)
• 2 - Assessment
• O2
• Monitor (BP, pulse) consider cardiac
  monitor, pulse ox
• Access (assure venous access)
• 3 Non-pharmacological measures
• Leg elevation
• Fluids
• 4 - Drugs

Consider calling CODE anytime 21212
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General approach to reactionsDrugs
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General approach to reactionsDrugs
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Epinephrine
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Most important Situations to deal

• Rash (hives, itching)
• SOB (wheezing)
• Hypotension
• Facil and Laryngeal edema
• Seizures

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• Case 1 34y/o female with skin reaction after
  administration of IV contrast

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General approach to reactionsRadiology Resident

• 1 - ABC (CPR)
• 2 - Assessment
• O2
• Monitor (BP, pulse) consider cardiac
  monitor, pulse ox
• Access (assure venous access)
• 3 - Drugs

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Hives

• No tretament needed most cases
• Consider Benadryl

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Disseminated HIVES

• Consider epinephrine 11000 0.1-0.3cc

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• Case 2 8 y/o male with SOB after administration
  of IV contrast

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General approach to reactionsRadiology Resident

• 1 - ABC (CPR)
• 2 - Assessment
• O2
• Monitor (BP, pulse) consider cardiac
  monitor, pulse ox
• Access (assure venous access)
• 3 Non-pharmacological measures
• Leg elevation
• Fluids
• 4 - Drugs

Consider calling CODE anytime 21212
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Bronchospasm

• Initial steps (including O2)
• Inhaler 2-3 puffs prn
• If no response
• Epinephrine 110.000 1cc IV slowly (up to 1mg)

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• Case 3 65 y/o male feels sick after
  administration of IV contrast. She is confused

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General approach to reactionsRadiology Resident

• 1 - ABC (CPR)
• 2 - Assessment
• O2
• Monitor (BP, pulse) consider cardiac
  monitor, pulse ox
• Access (assure venous access)
• 3 Non-pharmacological measures
• Leg elevation
• Fluids
• 4 - Drugs

Consider calling CODE anytime 21212
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Hypotension

• Initial steps (including leg elevation and
  fluids)
• If no response
• TACHYCARDIA Epinephrine 110.000 1cc IV slowly
  (up to 1mg)
• BRADYCARDIA Atropine 0.6-2mg IV (up to 3mg)
• If poor response
• Call code

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• Case 1 45y/o male does not look good

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General approach to reactionsRadiology Resident

• 1 - ABC (CPR)
• 2 - Assessment
• O2
• Monitor (BP, pulse) consider cardiac
  monitor, pulse ox
• Access (assure venous access)
• 3 Non-pharmacological measures
• Leg elevation
• Fluids
• 4 - Drugs

Consider calling CODE anytime 21212
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Facial or Laryngeal Edema

• Initial steps (including O2)
• Epinephrine 11000 0.1-0.3cc
• Consider intubation
• Call CODE earlier rather than later

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Hypotension

• Initial steps (including leg elevation and
  fluids)
• If no response
• Epinephrine 110.000 1cc IV slowly (up to 1mg)
• If poor response
• Call code

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• Case 5 51y/o male with seizure after
  administration of IV contrast

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General approach to reactionsRadiology Resident

• 1 - ABC (CPR)
• 2 - Assessment
• O2
• Monitor (BP, pulse) consider cardiac
  monitor, pulse ox
• Access (assure venous access)
• 3 Non-pharmacological measures
• Leg elevation
• Fluids
• 4 - Drugs

Consider calling CODE anytime 21212
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Seizure

• Initial steps (including O2, Pulse ox and
  securing airway
• Diazepan 5mg IV (may repeat if needed)
• Get appropriate consultation (may need phenytoin)

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Post Reaction Tasks

• 1 Call referring physician
• 2 Call nurse in the floor if inpatient
• 3 Document in the chart
• 4 Document Allergy in POE if appropriate
• 5 Inform patient about the future precautions
• 6 Report the reaction in the dictation

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• Other situations

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Infiltration of IV

• Elevate
• Ice Pack
• If gt30cc volume contact plastics monitor for
  compartment syndrome.

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Hypertension

• Nitroglycerine 0.4mg SL or 1 paste
• If due to pheochromocytoma phentolamine 5mg IV

Is feocromocytoma a contraindication to IV
contrast ?
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• Special situations

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Metformin (anti-diabetic agent)

• High levels of Metformin ? lactic acidosis if
  metformin levels too high (50 mortality)
• Patients should not be on metformin if their
  renal function is already compromised
• Hold metformin after contrast for 48h hours

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Pregnancy

• Only theoretical risks to unborn fetus and to
  breast feeding infants
• Use when needed, not for stupid studies or when
  alternatives are available
• Pump milk before exam, pump and discard for 24
  hours

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Dialysis

• As a rule patients should be dialyzed in the next
  24h.

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• Review
• What should I do if

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• Urticaria
• ABC and Vital signs
• Consider benadryl
• If disseminated then consider epinephrine
• SOB
• ABC and vital signs
• Start oxygen
• Inhaler
• If no improvement consider epinephrine and CODE
• Hypotension
• ABC, vitals, pulse ox, cardiac monitor, IV acces
• Elevate legs
• Fluids
• TACHYCARDIC Epi
• BRADYCARDIC Atropine
• Laryngeal edema
• ABC, O2, Pulse ox, cardiac monitor
• Epinephrine (11000)
• Consider intubation, CODE

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• Patient is on Metformin
• Check creatinine. If abnormal contact physician
• Stop metformin for 48h
• Patient is lactating
• Pump before the contrast
• Pump and discard milk for 12-24h after
• Patient has allergy to shellfish
• Nothing
• Patient has multiple allergies
• Most times, no premedication recommended
• Patient has elevated creatine
• Hydrate
• Consider mucomyst, bicarb, visipaque

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• Patient had hives in previous CT scan
• If possible pre-medicate
• Prednisone, benadryl, ranitidine
• Patient has multiple myeloma
• Try to avoid. Specially if increased Cr
• Patient had infiltration of contrast in the
  subcutaneous tissues
• Elevation and ice
• Consider evaluation by plastics
• Patient has asthma
• Make sure there is b-agonists available
• Patient complaints of hives
• ABC
• Benadryl if necessary
• Patient on dialysis
• Advise to dialyse within 24h