Radiology Life Support: Dealing with Acute Contrast Reactions William H. Bush, Jr., MD, FACR University of Washington

Contrast Use Test Yourself

Question # 1 A patient who has had a reaction to iodinated contrast is at higher risk for having a reaction to gadolinium agents. True or False ?

Question # 2 Your patient is cool, clammy, and has perspiration on their forehead and upper lip. The reaction most likely occurring is: 1. Vagal reaction 2. Urticaria 3. Bronchospasm

Question # 3 Your patient complains of shortness of breath. The most likely reaction occurring is: 1. Vagal reaction with bradycardia 2. Urticaria 3. Bronchospasm

Question # 4 Which of these IMMEDIATE actions by you during response to a major allergic-like systemic contrast reaction is the most important ? 1. I.V. access 2. Airway / suction / oxygen 3. Cardiac monitor / pulse oximeter 4. Blood pressure

Question # 5 Which of these IMMEDIATE actions by you during response to a major allergic-like systemic contrast reaction is the least important ? 1. Talk to the patient 2. Take their pulse 3. Take their blood pressure.

Question # 6 The treatment for severe hypotension and bradycardia is: (a, b or c) a.IV fluids and atropine b.IV fluids and epinephrine c.Nitroglycerine

Question # 7 The key finding for diagnosing a vagal reaction is: (a, b, c, or d) a. Rapidity of breathing b. Systolic blood pressure c. Diastolic blood pressure d. Pulse rate

Question # 8 The adult dose of IV atropine for treating a vagal reaction is: (a, b, or c) a mg b. 1.0 mg c. 0.3 mg

Question # 9 Initial treatment of laryngeal edema is: (a, b, c, or d) a.Atropine b.Benadryl® c.Beta-agonist inhaler d.Epinephrine

Question # 10 Your patient is hypotensive; the most effective route for epinephrine administration is: (a or b) a. Intravenously b. Subcutaneously

Question # 11 Adult dosage of IV epinephrine for treating a systemic anaphylaxis-like contrast reaction is: (a or b) a. 1 cc of 1:1,000 b. 1 cc of 1:10,000

Anticipate Potential Problems: Chemotoxic effects of contrast Anaphylaxis-like reactions

CONTRAST-INDUCED NEPHROTOXICITY Gadolinium is not nephrotoxic if given in usual does for MR imaging, e.g. 0.1 mmol/kg. However, in larger doses, there is increased risk to the kidneys.

GADOLINIUM, ADVANCED RENAL FAILURE, and SYSTEMIC TOXICITY Unresolved question of increased systemic toxicity to patients with advanced renal failure (e.g. GFR < 15cc/min) or on dialysis. Theory of Nephrogenic Systemic Fibrosis (NSF): Free Gd triggers the process. Three dialysis treatments removes 99% of the gadolinium.

Questions of Your Patient Hemodialysis; advanced renal failure Previous reaction to contrast * -obtain specifics Asthma * Allergies * * Allergic reactions are more likely when these patient factors exist.

ACUTE, ANAPHYLACTIC-LIKE REACTIONS from iodinated LOCM Moderate, non-life-threatening: % (1:250 injections) Severe, life-threatening: 0.04% (1:2500 injections)

ACUTE, ANAPHYLACTIC-LIKE REACTIONS with gadolinium agents Very uncommon Mayo Clinic: epinephrine was needed to treat a serious reaction in 1:20,000 injections of a gadolinium agent.

PREMEDICATION WHEN IS IT NECESSARY? History of a few scattered hives: No History of treatment for prior reaction: Yes

PREMEDICATION Prednisone 50 mg, PO, q 6 h x 3 (e.g. 13, 7, 1 hr) Diphenhydramine 50 mg, PO 1 hour before contrast Greenberger and Patterson J Allergy Clin Immunol 87: , 1991

PREMEDICATION Methylprednisolone (Medrol ®) 32 mg, PO, 12 and 2 hours before contrast Diphenhydramine 50 mg, PO 1 hour before contrast E. Lasser, et al N.Engl.J.Med 1987; 317:845-9

PREMEDICATION Corticosteroids: necessary to decrease risk of contrast reactions needing treatment Antihistamines: alone are not adequate

PREMEDICATION Corticosteroids are essential Need minimum of 6 hours before contrast (preferably longer) ** Reduces risk but does not eliminate it

Recognition & Treatment of Systemic Reactions

Patient Presentations Uncomfortable Calm, poorly responsive to commands Anxious, agitated

Responding to a Possible Reaction Quickly assess the situation Call for help Remove the patient from the MR suite (much of the emergency equipment is not MR- compatible)

Responding to a Possible Reaction Take their pulse Talk with them

Responding to a Possible Reaction Taking their pulse: 1. Palpable: systolic is mmHg 2. Rate: rapid or slow

Responding to a Possible Reaction Talking with the patient: 1. Assess for laryngeal edema 2. Assess degree of SOB 3. Assess responsiveness

Uncomfortable Skin reaction: Redness, itching, hives Nausea & vomiting

Uncomfortable Skin reaction: Redness, itching, hives Nausea & vomiting Plan: observation (may be first signs of a more serious reaction)

SERIOUS, LIFE-THREATENING REACTIONS

RESPONDING TO A SERIOUS REACTION Multiple tasks to accomplish 1. Airway / suction / oxygen 2. Obtain pulse; I.V. access 3. Leg elevation 4. Provide medications 5. Cardiac monitor / pulse oximeter 6. Obtain Blood pressure Take “ownership” of a task

Calm, Unresponsive Hypotension Hypoglycemia

HYPOTENSION With Tachycardia With Bradycardia

HYPOTENSION WITH TACHYCARDIA Leg elevation (approx. 60°) Oxygen by mask ( 6-10 L/min ) IV fluids (normal saline or Ringer’s lactate) Treatment includes :

HYPOTENSION WITH BRADYCARDIA Leg elevation (approx. 60°) Oxygen by mask ( 6-10 L/min ) IV fluids ( normal saline or Ringer’s solution) Atropine IV Treatment includes:

VAGAL REACTION Key finding = decreased pulse rate

ATROPINE Give if bradycardia is symptomatic Recommended dose : Adult IV dose range: mg My preference: 1.0 mg as initial dose

Anxious, Agitated HYPOXIA (lack of oxygen)

ACUTE BRONCHOSPASM Recommended treatment: Beta-2 agonist inhaler (2 - 3 puffs) Supplementary treatment: Epinephrine

LARYNGEAL EDEMA Goals: Oxygenation Reduce edema of upper airway Treatment: Oxygen by mask Epinephrine, 1:10,000 IV

EPINEPHRINE: Route of Administration If hypotension is not significant – can use I.M. or subcutaneous route With significant Hypotension – Use IV

Epinephrine for I.V. use

EPINEPHRINE (Adrenalin) INTRAVENOUS: 1:10,000 (1 mg in 10 ml) 10 ml = 1000 mcg 1 ml = 100 mcg Start with 1 ml given slowly (deliver the 100 mcg over 2-5 minutes)

EPINEPHRINE: Route of Administration If hypotension is not significant – can use I.M. or subcutaneous route

EPINEPHRINE (Adrenalin) SUBCUTANEOUS OR I.M. ( * if not hypotensive ) 1:1000 (1 mg in 1 ml) 1 ml = 1000 mcg 0.5 ml = 500 mcg 0.1 ml = 100 mcg Start with 0.1 or 0.2 ml

EPINEPHRINE PROBLEMS: 1. Not giving it 2. Giving it too late 3. Giving too much 4. Giving it so that it is not absorbed effectively

EPINEPHRINE Recommended initial I.V. Dose: 1 ml of 1:10,000 epinephrine (100 mcgm) given slowly over 2 – 5 minutes Additional amounts can be given if the patient does not respond adequately

LARYNGEAL EDEMA Beta-2 agonist inhaler: may make edema worse Benadryl®: thickens secretions; may cause hypotension

AD BENRYL

PEDIATRIC REACTIONS Children have good hearts If a problem develops, think AIRWAY

RESUSCITATION Airway: – clear, suction – jaw lift – oral airway Ventilation: – mouth-valve-mask – bag-valve-mask (Ambu ® )

OXYGEN IS GOOD ! ( for all reactions )

OXYGEN Nasal cannula: 2 – 6 L/min provides only 25 – 40% concentration Simple mask: 6 – 10 L/min provides 35 – 60 % concentration (Flow rate at least 6 L/min to prevent carbon dioxide build-up in mask)

OXYGEN Via mask High flow rate ( 6 – 10 L / min. )

RESPONDING TO A SERIOUS REACTION Multiple tasks to accomplish 1. Airway / suction / oxygen 2. Obtain pulse; I.V. access 3. Leg elevation 4. Provide medications 5. Cardiac monitor / pulse oximeter 6. Obtain Blood pressure Take “ownership” of a task

QUIZ REVIEW

Answer to Question # 1 A patient who has had a reaction to iodinated contrast is at higher risk for having a reaction to gadolinium agents. True or False ? (depending on the prior reaction, consider premedication for the gadolinium study)

Answer to Question # 2 Your patient is cool, clammy, and has perspiration on their forehead and upper lip. The most likely reaction occurring is: 1. Vagal reaction 2. Urticaria 3. Bronchospasm Treatment: I.V. fluids + atropine

Answer to Question # 3 Your patient complains of shortness of breath. The reaction most likely occurring is: 1. Vagal reaction with bradycardia 2. Urticaria 3. Bronchospasm Treatment: Beta-2 agonist inhaler; epinephrine

Answer to Question # 4 Which of these IMMEDIATE actions by you during response to a major allergic-like systemic contrast reaction is the most important ? 1. I.V. access 2. Airway / suction / oxygen 3. Cardiac monitor / pulse oximeter 4. Blood pressure

Answer to Question # 5 Which of these IMMEDIATE actions by you during response to a major allergic-like systemic contrast reaction is the least important ? 1. Talk to the patient 2. Take their pulse 3. Take their blood pressure.

Answer to Question # 6 The treatment for severe hypotension and bradycardia is: (a, b, or c) a. IV fluids and atropine b. IV fluids and epinephrine c. Nitroglycerine

Answer to Question # 7 The key finding for diagnosing a vagal reaction is: (a, b, c, or d) a. Rapidity of breathing b. Systolic blood pressure c. Diastolic blood pressure d. Pulse rate

Answer to Question # 8 The adult dose of IV atropine for treating a vagal reaction is: (a, b, or c) a.5-10 mg b.1.0 mg c.0.3 mg

Answer to Question # 9 Initial treatment of laryngeal edema is: (a, b, c, or d) a.Atropine b.Benadryl® c.Beta-agonist inhaler d.Epinephrine

Answer to Question # 10 Your patient is hypotensive; the most effective route for epinephrine administration is: (a or b) a. Intravenously b. Subcutaneously

Answer to Question # 11 Adult dosage of IV epinephrine for treating a systemic anaphylaxis-like contrast reaction is: (a or b) a. 1 cc of 1:1,000 b. 1 cc of 1:10,000

THANK YOU