Contrast Media ACR guidelines 2022.

This manual give us recommendation and training of use of contrast media in proper way and to manage any reaction if occur.

1. Amarjeet Kumar B.Sc. MIT, M.Sc. MIT, MPA Radiology Technologist JPNATC AIIMS DELHI 1

2. ACR MANUAL OF CONTRAST MEDIA 2022

3. purpose Various forms of contrast media have been used to improve medical imaging. To assist radiologists & technologist in recognizing and managing the small but real risks inherent in the use of contrast media. Adverse side effects from the administration of contrast media vary from minor physiological disturbances to rare severe life - threatening situations. Trained personnel, equipment, and medications. 3

4. Patient selection strategy 1. Assessment of patient risk versus potential benefit of the contrast-assisted examination. 2. Imaging alternatives that would provide the same or better diagnostic information. 3. Assurance of a valid clinical indication for each contrast medium administration. 4

5. Patient selection strategy (Cont..) 1) to ensure that the administration of contrast is appropriate for the patient and the indication; 2) to balance the likelihood of an adverse event with the benefit of the examination; 3) to promote efficient and accurate diagnosis and treatment. 4) to be prepared to treat a reaction should one occur . 5

6. Is fasting Prior to Intravascular Contrast Media Administration is needed ? 6

7. Types of contrast media 7

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10. Administration of CM HAND INJECTION PRESSURE INJECTOR 10

11. Commonly used technique PRESSURE INJECTOR 11

12. IV Cannula flow rate MAX. FLOW RATE (ml/sec) 18G 24G 22G 20G 16G 1 2 3 4 5 PINK GREY GREEN YELLOW BLUE 12

13. Is contrast media warming is needed ?

14. Warming of contrast media needed in: Extrinsic warming of body temperature (37°C) may be helpful to minimize complications and improve vascular access. For high-rate (> 5 mL/second) IV LOCM power injections. For higher viscosity contrast such as iopamidol 370. For direct arterial injections through small-caliber catheters (5 French or smaller). For intravenously injected arterial studies in which timing and peak enhancement are critical features 14

15. 15 What is this condition called ?

16. Extravasation of CM Less Reported non frequent Patient complain of swelling and burning pain at injection site. Does not depend on flow rate. Toxic to surrounding tissue. May cause compartment syndrome. Less commonly Skin ulceration and tissue necrosis can occur. Treatment include cold and heat compression Elevation of limb or extremity above the heart level. If volume extravasated is more than 100ml surgical consultation is needed prior to discharge and follow ups taken for next 24 hours. 16

17. Who are at more risk of contrast extravasation ? Those who cannot communicate adequately. (eg. Infant, elderly and children) Patients severely ill or debilitated patients. Abnormal circulation in the limb to be injected(eg. Venous thrombosis, prior radiation therapy or extensive surgery. Certain intravenous sites (e.g. hand, wrist, foot, ankle) are more likely to result in extravasation. IV lines placed for more than 24 hours and multiple puncture sites. 17

18. Risk factor for adverse events Allergy Asthma Renal insufficiency cardiac status anxiety 18

19. Contrast reactions or Acute adverse events Acute adverse events can be categorized as either allergic-like or physiologic, and organized into three general categories of severity (mild, moderate, or severe) Low incidence due to changing Iodinated contrast media from HOCM to LOCM. majority of adverse side effects to LOCM are mild non-life-threatening Severe and potentially life-threatening adverse events continue to occur rarely and unpredictably within 20 min of contrast administration. Delayed contrast reaction may also occur. 19

20. Gadolinium based contrast reactions 20

21. Does contrast media affects kidney ? 21 The diagnosis of Post Contrast - Acute kidney injury (PC- AKI) is made according to the KDIGO criteria if 1) Absolute serum creatinine increase ≥0.3 mg/dL (>26.4 µmol/L). 2) A percentage increase in serum creatinine ≥ 50% (≥1.5-fold above baseline). 3) Urine output reduced to ≤ 0.5 mL/kg/hour for at least 6 hours

22. KFT test needed or not ? 22 Serum creatinine concentration is the most commonly used measure of renal function, but it has limitations as an accurate measure of glomerular filtration rate (GFR). Calculated estimated glomerular filtration rate (eGFR) is more accurate than is serum creatinine. eGFR calculation https://www.kidney.org/professionals/kdoqi/gfr_calculator

23. Treatment of contrast reaction 23 Starts with a well-designed plan and a properly trained staff. Basic life support training, on-site personnel should be trained in the rapid recognition, assessment, diagnosis, and treatment of contrast reactions.

24. In evaluating a patient for a potential contrast reaction, five immediate assessments should be made if clinically feasible: 24 What is the patient’s general appearance ? Can the patient speak ? How does their voice sound ? What is the quality of the patient’s breathing ? What is the patient’s pulse ? What is the patient’s blood pressure ?

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27. The following minimum medications & equipment should be within or near any room in which contrast media is to be injected: 27 MEDICATION: • Epinephrine IM 1mg/1mL (auto-injector or vials with needle and syringe for use) • Inhaled short-acting beta-agonist (inhaler or nebulizer) • Anti-histamine EQUIPMENT: • Access to oxygen • Defibrillator or automated external defibrillator (AED) • Blood pressure and pulse monitor • Pulse oximeter • Stethoscope

28. The following discretionary medications and equipment may be considered for inclusion within or near any room in which contrast media is to be injected: 28

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34. 34 Thank you