CME presentation Safwan. Preparation for CT scan

Patient preparation for CT scan procedure

1. PATIENT PREPARATION F O R C T S C A N E X A M I N A T I ON MUHAMMAD SAFWAN BIN SUILE RADIOGRAPHER U29 QUEEN ELIZABETH HOSPITAL

2. Request & Consent Forms Patient preparation for pre, and post examination of CT Scan General Specific T ABLE O F CONTENT

3. 1. R E QUE S T AND CONSENT FORMS

4. Surat Punca Kuasa perlaksanaan borang baru

5. Radiology request form Circular 2018 PER.SS-RA301 (P i nd1/20 16 ) t o b e r e pla ce d wi t h (Pind. 1/2018) If report needed, do copy.

6. Request form

7. CONSENT PREGNANT LADY When to take consent All radiological examinations where ionizing radiation (x-ray) is used such as plain radiography, fluoroscopic examinations and CT examinations. Magnetic Resonance Imaging examinations. Who to take consent The requesting doctor to be obtained on the day of request. The Radiology doctor on the day of the examination. A medical officer may obtain the consent from the patient; however the form has to be counter-signed by the attending specialist.

8. CONSENT PREGNANT LADY How to take consent The requesting doctor will explain more on the need and benefits of the procedure, available alternatives and how it will help in patient’s subsequent management. The Radiology doctor will explain on the possible risks and complications towards patient and the fetus. For plain radiography, requesting medical officer shall take the consent after consulting their respective specialists. For special X-ray examinations, CT examinations and MRI examinations, the consent shall be taken by the requesting doctor and Radiology doctor accepting the case after consultation with the Specialists. The consent shall be taken from patient herself. In the event she is not capable of doing so, consent may be taken from guardian / relative. If the procedure requires the injection of a contrast medium, the consent form for radiological procedures with contrast medium must be completed along with the checklist.

9. PREPARATION For lactating Patients According to the 'Royal Australian and New Zealand College of Radiology' and ' Lactmed ’, there is no need to stop breastfeeding after receiving an iodine-based contrast medium during a CT scan. Less than 1% of the iodine-based dye is present in breast milk within the first 24 hours. Breastfeeding may be continued as usual (Western Sydney Local Health District, 2019). There is no evidence that this small amount is harmful to the baby. Therefore, it is generally safe to continue breastfeeding after a CT scan (Ellis, 2021).

10. When to take consent? For radiological procedure that may require contrast medium (Intravenous urography (IVU), Computed tomography (CT), Magnetic resonance imaging (MRI), Angiography etc). Who to take consent? The requesting doctor obtained on the day of request. Radiology doctor on the day of the examination. A medical officer may obtain the consent from the patient; however the form has to be counter-signed by the attending specialist.

11. How to take consent? Complete the checklist for high risk (part B) in the consent form. The requesting doctor shall explain the patient’s condition, the need for the investigation and how it is going to alter the management. The radiology doctor shall explain on the procedure itself and the possible complications. The consent shall be taken from patient himself/herself. In the event he/she is not capable of doing so, consent can be taken from guardian / relative.

12. P A TIENT PRE P A R A TION GENERAL SPECIFIC

13. Clothing Comfortable, loose fitting, without metal objects (zippers, button, jewelry)- change to hosp. gown Food and drink Depending on the type of CT Scan – avoid eating or drinking for a few hours before examination Medications Should continue medications unless Dr tells you otherwise

14. Allergies Inform to doctor/radiographers if patient have any allergies esp. to contrast (iodin) Pregnancy If you are thinking that the patient pregnant (LMP) or might be pregnant, inform to Dr. First trimester (first 3 months or 12 weeks) Other medical condition Inform Dr if patient have diabetic or kidney disease

15. SP E CIFI C PRE P A R A TI O N

16. Request & consent form Ensure request form has been completed with signed by Medical Specialist, patient witness and Radiology MO Allergy Patients have allergy/history of allergy > covered by steroids (prednisolone 40mg) 12 hours before and 2 hours, still have allergy after CT > steroid (hydrocortisone 20 mg – 240mg orally, IV) 12 hours > to cover allergy reaction after CT examination Enough time for medication to be absorbed > start working to reduce inflammation and prevent allergy reaction 2 hours > cover immediate reaction Not necessarily absorbed, intend to help reduce immediate allergy reaction Suppressing immune system's response to contrast medium

17. Allergic to seafood (some people who have allergic to seafood + iodinated contrast) 70-80% people allergic to seafood but not contrast American College of Radiology. ACR (2017), Hagan J. B., et all. 2012, Kopp A. F., 2004 & Laroche D., 1999 Medication (diabetes medication > Metformin > effect kidney function >increase risk lactic acidosis) Should be stopped 48 hours before the examination to reduce Lactic Acidosis – affect ability to use oxygen properly > nausea, vomiting, abdominal pain etc. Iodin contrast lead to CIN (Contrast induce nephropathy) > increase the risk of Lactic Acidosis Metformin + Iodin > more risk to Lactic Acidosis (National Center for Biotechnology Information, 2019 - Metformin- Associated Lactic Acidosis (MALA)

18. 4. Ensure eGfr (Assess Kidney functioning) and Creatinine Creatinine – waste product produced by the muscles and filtered out by the kidney High creatinine > kidney not function properly Common situation - eGfr low will cause creatinine reading high Male creatinine accepted to do CT (60 - 110µmol/L, female 45 - 90µmol/L) *Male have more muscle mass eGFR (estimated glomerular filtration rate)> how well your kidneys > blood test, age, sex, body type and race. Medical News Today_ www.medicalnewstoday.com/articles/320113

19. 5. Kidney Protection N- acetylcyteine (NAC) to help protect kidney from damaged caused by contrast medium NAC taken 2 hours before examination - allow enough time to absorb and start working American family physician_ www.aafp.org/afp/2016/0115/p104.html Request & consent form Ensure request form has been completed with signed by Medical Specialist, patient witness and Radiology MO IV line functioning properly Pink (Normal examination- portal vein phase lesion > Thorax, Abd etc Grey/Green > CTA/CTPA – Rt Side Antecubital Rt side Antecubital - RAV will travel directly to the heart and lungs, resulting in better image quality. ( American College of Radiology 2020). Lt side Antecubital - travel through the superior vena cava (SVC) to reach the heart and lungs, (some dilution of the contrast media). (Fang et al. 2015)

20. O l d X - R a y f il m s If required, to compare previous condition Fasting for at least 4 hours To ensure the digestive system is empty - the accumulated gas in the stomach and intestine create artifact Aspiration – food/ liquid inhaled into lung > coughing, choking, breathing difficulty > pneumonia Drink oral contrast, plain water, rectal contrast or full bladder for certain CT examination To improve visibility of certain structure or organ in the body Warm the contrast to closure to temp of patient body (37°C) > reduce discomfort Administer sedative If required, to remain still and calm, to help patient relax due to anxiety, claustrophobia etc.

21. American College of Radiology. ACR Manual on Contrast Media. Version 10.3. 2017. https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf "N-Acetylcysteine for the Prevention of Contrast-Induced Nephropathy" from American Family Physician: https://www.aafp.org/afp/2016/0115/p104.html "Creatinine: What is it and what do the results mean?" from Medical News Today: https://www.medicalnewstoday.com/articles/320113 American College of Radiology. ACR Manual on Contrast Media. Version 10.3. 2017. https:// www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf Hagan JB, Samant RS, Volcheck GW. Allergic Reactions to Radiocontrast Media. Allergy Asthma Proc. 2012;33(6):461-466. doi:10.2500/aap.2012.33.3606 Western Sydney Local Health District. (2019). Breastfeeding your baby after an MRI or CT scan . Ellis, J. (2021). Michigan Medicine. CT Scan While Breastfeeding Fang, H., Song, Y. L., Li, X. S., Bi, Y. M., Wang, P., Fan, H. X., Meng, L. M., & Hu, H. X. (2015). Right arm injection of contrast medium reduces venous artifacts in head and neck multislice spiral computed tomography angiography.  European review for medical and pharmacological sciences ,  19 (24), 4698–4702. American College of Radiology. (2020). ACR Appropriateness Criteria® cardiac imaging topics. Retrieved January 13, 2020, from http://www.acr.org/Quality-Safety/Appropriateness-Criteria

22. THANK Y OU