Center for Advanced MRI

II. POLICY

Gadolinium based contrast media is administered to enhance imaging. Radiology Registered Nurses, Technologists, and Attending Radiologists administer contrast. Subjects are managed to minimize clinical risks. The Radiology department provides policies and procedures that will enable the provision of appropriate and safe care to all patients.

III. PERSONS OR AREAS AFFECTED

This policy applies to all employees, Principal Investigators, and research affiliates and personnel of the Department of Radiology at Northwestern University involved in the injection or monitoring of patients receiving intravascular Gadolinium based contrast media.

IV. RESPONSIBILITIES

A. The Directors of the Center for Advanced Magnetic Resonance Imaging are responsible for development and implementation of policies/procedures that address Department issues and ensure compliance with University and Hospital standards.

B. The management team in the Radiology Department is also responsible for ensuring that all employees comply with these policies and procedures.

C. Employees are responsible for being knowledgeable about and complying with University-wide and Department-specific policies.

V. PROCEDURES

A. Contrast media shall be selected, prepared and administered:

1. According to manufactures’ recommendations and IRB approved guidelines
2. With knowledge of subject’s medical history and condition
3. According to appropriate sterile procedures.
4. In the immediate vicinity of a defibrillator and access to 911 for off-site facilities.
5. In the department of radiology with an emergency drug box in the treatment area.

B. Administration of Intravenous Contrast Prior to injecting intravenous contrast material, the radiologist, radiology nurse and/or technologist shall do the following:

1. Conduct a patient pre-exam inquiry/questionnaire and history including:
• Indications and contra-indications of contrast administration
• Method of administration and dosing
• Possible adverse reactions and/or complications
• Reaction to previous injections of diagnostic contrast media
• Current medication list pertinent to contrast administration
• Presence of loose teeth and/or removable dental fixtures

1. Confirm that oxygen, suction unit and airways in room are in working order.
2. Confirm that emergency drug boxes containing medications to treat contrast reactions are immediately available in the treatment area and checked daily in all radiology departments where contrast is administered.
3. Confirm that the cardiac arrest cart is immediately accessible and checked daily when contrast is being administered.
4. Confirm that the cardiac arrest cart is immediately accessible and checked daily when contrast is administered according to Patient Care Policy #3-Emergency Medical Response: Cardiac, Airway, and Medical Emergency Teams.

C. For subjects receiving intravenous gadolinium based contrast media, an estimated Glomerular filtration rate (eGFR) will be obtained on the day of the exam using point of care testing (defined as within 24 hours. Please refer to Radiology policy #1-Administration of Gadolinium Based Contrast Media for specific laboratory screening and instructions on gadolinium based contrast media). eGFR results will be reviewed by radiology nurse and or radiologist and if the result is abnormal based on departmental protocols, the study will be canceled.

D. A point of care creatinine result of greater than 1.5 will be verified through laboratory Services and will be communicated to the ordering physician and principal investigator.

E. Injection and post injection:

1. Only attending radiologists, radiology house staff, and approved radiology registered nurses and technologists perform the injection of intravenous contrast material. Subjects remain under observation throughout the infusion process.
2. Only radiology nursing and physician staff will insert and assess peripheral intravenous catheters. Technologists may complete power or hand injection into peripheral lines.
3. Contrast administered with a power injector may only be administered through a peripheral intravenous catheter, manufacturer approved power injector catheter (example power PICC) or a single lumen introducer (Cordis) catheter (without swan present).
4. All central lines must be accessed per Nursing Care Policy Central Venous Access Devices (managed by registered nurses only).
5. MRI technologists may hand inject a central line (through an established IV infusion line) once the line is accessed by a registered nurse.
6. An approved central line used for contrast administration on a subject will be flushed per the patient’s home protocol. If protocol is unknown, the line will be flushed with 20cc of normal saline and subject will be instructed to follow their home protocol upon discharge.
7. For every procedure performed involving the injection of intravenous contrast material, the amount and type of contrast administered, eGFR results, as well as the patient’s tolerance of the contrast must be documented on the procedural record for contrast.

F. Reporting of Contrast Reactions

1. All contrast reactions, including minor reactions, require immediate notification of the attending physician or house staff radiologist. If appropriate, medications shall be administered to treat the reaction as ordered by the radiologist.
2. The radiology nurse will record the patient name, the reaction, and the treatment of a contrast reaction and will document this on the procedural record for contrast.

G. Identifying Reactions

1. Reactions to contrast agents are categorized as minor, moderate or severe by the American College of Radiology (ACR) criteria.
• Severe reactions including severe and prolonged hypertension, coma, convulsion, pulmonary edema, laryngeal edema, severe bronchospasm and arrhythmia.
• Moderate reactions can be stable or progress to a major reaction and include hypotension or hypertension of short duration, mild bronchospasm, dyspnea, wheezing, slowly resolving cutaneous reactions including rash and urticaria.
• Minor reactions are often self-limited and treatment is frequently not necessary. Minor reactions imclude: nausea, vomiting, light-headedness, vertigo, dizziness, sweating, itching, urticaria, salivary gland swelling, arm pain, facial edema, chills, sneezing. With all minor reactions each case must be reviewed. In some instances the reaction may be vasovagal, related to the stress of injection and not the contrast material. Any cutaneous reactions such as rash, urticaria and itching should be considered a true reaction even if mild and not treated. Salivary gland swelling and chills should also be carefully evaluated on a case by case basis. The remainder of the “minor reactions” may well not represent the true allergic reactions to contrast agents.

2. A short statement describing the reaction and treatment will be included on the contrast volunteer record form.

3. Subjects will be assessed by a nurse who will consult with an attending physician or radiologist and will be given a “Patient Discharge Instructions: Contrast Allergy” sheet. Subjects experiencing a contrast reaction shall be observed by a radiology research nurse for stability at least 30 minutes prior to leaving the facility. Subjects are referred to their attending physician or emergency department for post reaction assessment and care as needed. Follow up patient assessment is made on all subjects (via phone call) is made by a radiology nurse within 24 hours.

L. Extravasation of Contrast

All extravasations of contrast require notification and assessment by the radiology staff. Documentation of extravasation is completed on a contrast reaction volunteer record form. Subjects are given a “Discharge Instructions Extravasation Sheet”. Follow-up assessment on all subjects (via phone call) is made by a radiology nurse within 24 hours.

VI. RELEVANT REGULATORY REFERENCE:

Manual on Contrast, Media, American College of Radiology, Version 6, 2008 www.acr.org/SecondaryMain MenuCategories/quality_safety/contrast_manual.aspx-Text Version

VII. CROSS REFERENCE:

NMH Policy # 2.03 RAD: Contrast Administration and Reaction Management

Responsible Party:

James Carr, MD
Associate Professor
Director, Cardiovascular Imaging

Todd Parrish, PhD
Director of the Center for Advanced MRI