Intravenous Contrast Agent Guideline

The following is intended to serve as a guideline for performing diagnostic studies that require contrast medium. Each case is unique and there will be times when the benefit of information gained from contrast administration will supersede the potential risk of reaction or renal toxicity. The following guidelines may not apply in these cases or in life threatening emergencies.

The following is intended to serve as a guideline for performing diagnostic studies that require contrast medium. Each case is unique and there will be times when the benefit of information gained from contrast administration will supersede the potential risk of reaction or renal toxicity. The following guidelines may not apply in these cases or in life-threatening emergencies.

  1. A current creatinine level must be available for all inpatients and for outpatients over 6o years of age prior to administration of intravenous contrast. “Current” is defined as within one month for outpatients and within one week for inpatients.  Please also reference a complete list of the recommended indications for measurement of serum creatinine (Who must have a creatinine level prior to IV contrast?)
  2. Patients with an elevated creatinine should receive intravenous contrast only if absolutely necessary. The following table provides a guideline for the use of contrast by type relative to the patients creatinine (mg/dL) or eGFR (%):

    UW Guidelines for Contrast Selection

    Diabetic

    Contrast Creatinine eGFR
    Iohexol ≤ 1.4 > 50
    Iodixanol 1.4 – 1.8 50-40
    No Contrast > 1.8 < 40

    Non-Diabetic

    Contrast Creatinine eGFR
    Iohexol < 1.8 > 40
    Iodixanol 1.8 – 2.4 40-30
    No Contrast > 2.4 < 30
  3. For an acutely traumatized patient for whom there is insufficient time to obtain a creatinine level, it is understood that the benefit of making an emergent diagnosis of a life-threatening injury outweighs the risk of contrast nephrotoxicity.
  4. Patients who have chronic renal failure and are on chronic dialysis may receive contrast. While the timing of contrast administration is not dependent upon dialysis, it is preferable that the next routine dialysis occurs within 24 hours following contrast. Contrast should be avoided in patients who are experiencing acute dialysis-dependent renal failure as there is hope that renal function will recover. However, contrast may be administered in this setting if the referring physician deems it necessary.
  5. Patients with multiple myeloma, sickle cell disease, homocystinuria, or active gout may receive intravenous contrast but should be well hydrated.
  6. Patients who report an allergy-like reaction to contrast may be premedicated according to protocol at the discretion of the radiologist. Resuscitation equipment and drugs should be readily available.
  7. Patients who report “passing out” or who needed resuscitation after past contrast injections, should have iodinated contrast only if alternative testing will not provide a satisfactory result. Same should apply to patients with allergic asthma or multiple severe allergies.
  8. Contrast reactions could be potentiated by anxiety. Therefore, if a patient is exceedingly anxious prior to contrast injection, they may be premedicated with: Midazolam, 2 mg IV titrated up to a maximum of 5 mg (contraindication = glaucoma)

Jessica Robbins, June 2015

Treatment of nonionic radiographic contrast material extravasation

Details of treatment, including link to patient Health Facts for You (HFFY) sheet

Initial treatment provided by the radiology technologist includes:

  • Elevation of affected extremity above the heart
  • Removal of any tight fitting clothing above the injection site
  • Milk the extravasated contrast toward the heart by intermittent compression of affected site by manual compression or an Ace wrap

Observation performed by nursing staff includes:

  • Typical observation periods of 1-2 hours are sufficient
  • Educate patient about signs of tissue compromise, and advise to seek medical attention if needed per UW Health Facts for You (HFFY)
  • Plastic surgery consultation based on symptoms, not quantity of extravasation

Plastic surgery consultation should be considered for any of the following reasons:

  • Skin blistering
  • Redness or streaks at the injection site
  • Altered tissue perfusion (decreased capillary refill in the region or distal to the injection site)
  • Increasing pain
  • Change in sensation distal to site of extravasation

Patient given Health Facts for You (HFFY) by rad tech if responsive, or printed by nursing prior to discharge.

Bicarb Protocol

Interventional Radiology Bicarb Protocol for CIN

Indication

Radiocontrast nephropathy is a common cause of hospital acquired acute renal failure and has been associated with an increased in-hospital mortality and LOS.1-2

Various prevention strategies have been employed such as pre and post procedural hydration, vasodilators and acetylcysteine administration.

A study from JAMA printed in May of 2004 indicates that hydration with a bicarbonate solution may better prevent contrast induced nephropathy than NS hydration. Most renal failure is associated with metabolic acidosis and low urinary pH. NS may contribute to acidosis while the bicarbonate solution will buffer the pH.3

Other advantages of this prevention strategy are the low cost, lack of side effects and ability to administer in a timely manner.

Administration/Dosing

Solution: 150 mEq NaHCO3 in 1000cc D5W

  1. 1 hour prior to contrast: Initial IV bolus – 3ml/kg/hour x 1 hour
  2. After 1 hour bolus: 1ml/kg/hour during contrast exposure and 6 hours post contrast.

References

  1. Levy EM, Viscoli CM, Hurwitz RI. The effect of acute renal failure on mortality: a cohort analysis. JAMA. 1996; 275: 1489-1494.
  2. McCullough PA, Wolyn R, Rocher LL, et al. Acute renal failure after coronary intervention. Am J Med.1997; 103: 368-375.
  3. Merten GJ, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA. 2004; 291: 2328-2334.

2004/Lisa Semmann, R.N., M.S., Interventional Radiology NP