Teaching Module II - Upcoming Events : Teaching Module II Acute non-renal reactions to iodinated and...
Transcript of Teaching Module II - Upcoming Events : Teaching Module II Acute non-renal reactions to iodinated and...
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Teaching Module II
Acute non-renal reactions to iodinated
and Gd-based CM plus US-agents
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Acute non-renal reactions to
Iodinated and Gd-based CM
This slide deck was prepared by
Henrik S. ThomsenDirector & Professor, Department of Diagnostic Sciences,
Faculty of Health Sciences, University of Copenhagen, Denmark
& Consultant, Department of Diagnostic Radiology,
University of Copenhagen Herlev Hospital,
Herlev, Denmark
April 13th, 2010
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It must be totally inert.
The ideal contrast medium
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It must be totally inert.
It may not have any interaction with the organism at any level.
The ideal contrast medium
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It must be totally inert.
It may not have any interaction with the organism at any level.
It must be excreted fast and completely.
The ideal contrast medium
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The ideal contrast medium
It does not exist.
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Acute
Non-acute
Adverse reactions
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Acute < 60 min after exposure
Non-acute > 60 min after exposure
Adverse reactions
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Acute < 60 min after exposure
• Renal, e.g. CIN
• Non-renal, e.g. anaphylactoid reactions
Non-acute > 60 min after exposure
• Late: 60 min – 7 days after exposure,
e.g. skin rash
• Very late: > 7 days after exposure,
e.g. NSF
Adverse reactions
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Mild
• Nausea, mild vomiting
• Urticaria
• Itching
Moderate
• Severe vomiting
• Marked urticaria
• Bronchospasm
• Facial/laryngeal edema
• Vasovagal attack
Severe
• Hypotensive shock
• Respiratory arrest
• Cardiac arrest
• Convulsion
Non-renal acute adverse reactions
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Mild
• Nausea, mild vomiting
• Urticaria
• Itching
Moderate
• Severe vomiting
• Marked urticaria
• Bronchospasm
• Facial/laryngeal edema
• Vasovagal attack
Severe
• Hypotensive shock
• Respiratory arrest
• Cardiac arrest
• Convulsion
Non-renal acute adverse reactions
Requires treatment
The same for all
agents
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Mild
• -
• 1-15%
• -
Moderate
• -
• 0.2-0.4%
• -
• -
• -
Severe
• -
• < 0.01%
• -
• -
Non-renal acute adverse reactions
Requires treatment
Figures for non-
ionic Iodine based
agents
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Incidence of acute reactions to ICM
HOCM LOCM
Mild 5 - 15% 1 - 3%
Moderate 2% 0.2%
Severe 0.2 - 0.04% 0.04 - 0.004%
Katayama et al., Radiology 1990; 175:621-628
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Incidence of acute reactions to ICM
HOCM LOCM
Mortality 1 : 170,000 1 : 170,000
Katayama et al., Radiology 1990; 175:621-628
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Non-renal acute adverse reactions
Iodine based agents > Gadolinium based agents > US-agents
No difference in the prevalence of acute adverse reactions amongst the various non-ionic iodine based agents
No difference in the prevalence of acute adverse reactions amongst the various gadolinium based agents
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Patient-related
Patient with a history of:
• Previous moderate or severe acute reaction
• Asthma
• Allergy requiring medical treatment
Risk factors for non-renal acute adverse
reactions
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History of allergy X 3
History of previous adverse reactions to CM X 5
History of bronchial asthma X 6-10
Incidence of severe reactions
Katayama et al., Radiology 1990; 175:621-628
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Patient-related
Patient with a history of:
• Previous moderate or severe acute reaction
• Asthma
• Allergy requiring medical treatment
Contrast-medium-related
High-osmolar ionic iodine-based contrast medium
Risk factors for non-renal acute adverse
reactions
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Acute adverse reactions
Low-osmolar I-CM Gd-CM
Number of injections 298,491 158,439
Adverse reactions 0.15% 0.04%
Mild 374 (81.6) 49 (76.6)
Moderate 69 (15.1) 11 (17.2)
Severe 15 (3.3) 4 (6.3)
Needing treatment 79 15
Hunt et al., AJR 2009; 193(4):1124-7
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Risk factors for acute reactions with Gd-CM
• Previous moderate or severe reaction to CM (ICM or Gd-CM)
• Asthma
• Allergy requiring medical treatment
Niendorf et al., Magn Reson Med 1991; 22:222-228
Dillman et al., AJR 2007; 189:1533-1538
Acute reactions increase by a factor of 3-4
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To reduce the risk of a non-renal acute
adverse reaction
For all patients
• Use a non-ionic iodine-based contrast medium for X-ray.
• Keep the patient in the Radiology Department for 30 min after
contrast medium injection.
• Have the drugs and equipment for resuscitation readily available.
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To reduce the risk of a non-renal acute
adverse reaction
For patients at increased risk of a reaction
• Consider an alternative test not requiring an iodinated contrast
agent.
• Use a different iodinated agent for previous reactors to contrast
medium.
• Consider the use of premedication. However, clinical evidence of
the effectiveness of premedication is limited.
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Premedication (opinions are divided)
Corticosteroids
• Prednisolone 30 mg orally or methylprednisolone 32 mg orally 12 and 2
hours before contrast medium.
• Corticosteroids are not effective if given less than 6 hours before contrast
medium.
Antihistamines H1 and H2 may be used in addition to corticosteroids, but
opinions are divided.
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The brief administration of steroids is relatively safe and inexpensive but should
be avoided in patients with diabetes mellitus, active tuberculosis and in the presence of
systemic infection.
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Severe, even life-threatening reactions may still occur in patients who receive both corticosteroid premedication and low-
osmolar contrast media.
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Steroids
Katayama et al.
No beneficial effect of steroid premedication before non-ionic LO.
But it was given immediately before the contrast medium.
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Steroids
UK-survey
Only 55% of responders use corticosteroids.
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Steroids
UK-survey
Only 55% of responders use corticosteroids =
45% do not pretreat
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Steroids
UK-survey
Only 55% of responders use corticosteroids =
45% do not pretreat
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Despite preventive measures
• 8 patients out of 78,353 experienced 9 allergic-like reactions after
IV administration of Gd-CA, despite premedication.
Dillmann et al., AJR 2008; 190:187-190
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Despite preventive measures
• 8 patients out of 78,353 experienced 9 allergic-like reactions after
IV administration of Gd-CA, despite premedication.
• 1 patient had 2 breakthrough reactions.
Dillmann et al., AJR 2008; 190:187-190
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Despite preventive measures
• Eight patients out of 78,353 experienced 9 allergic-like reactions after
IV administration of Gd-CA, despite premedication.
• A single patient had 2 breakthrough reactions.
• 6 breakthrough reactions were mild, and 3 were moderate.
Dillmann et al., AJR 2008; 190:187-190
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Despite preventive measures
• Eight patients out of 78,353 experienced 9 allergic-like reactions after
IV administration of Gd-CA, despite premedication.
• A single patient had 2 breakthrough reactions.
• Six breakthrough reactions were mild, and 3 were moderate.
• No severe or fatal breakthrough reactions occurred.
Dillmann et al., AJR 2008; 190:187-190
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Despite preventive measures
• Eight patients out of 78,353 experienced 9 allergic-like reactions after
IV administration of Gd-CA, despite premedication.
• A single patient had 2 breakthrough reactions.
• Six breakthrough reactions were mild, and 3 were moderate.
• No severe or fatal breakthrough reactions occurred.
• 8 of 9 breakthrough reactions occurred in adults.
Dillmann et al., AJR 2008; 190:187-190
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Prevention
Be calm.
Be sure that drugs for first-line treatment are present –
the same emergency drugs and instruments for X-ray
and MR.
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Fact
Radiologist and trainee knowledge of immediate life-threatening contrast
reaction is deficient, e.g.:
• 53% of questions were answered correctly
• 43% knew the adrenaline dose
• Incorrect doses were mainly too high doses
• 45% knew the emergency telephone number
• 45% of rooms did not contain an immediately visible chart for contrast
reaction management
Bartlett et al., Australasian Radiology 2003; 47:363-367
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Easy access
Everything can be in
a trolley – remember
Report
Instructions
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Adrenalin
Only one concentration (1:1,000) of adrenalin should be
available in the radiology department to avoid confusion
under stressful emergency conditions.
The 1:1,000 preparation should be given only
intramuscularly.
Intravenous administration of adrenalin by
non-experienced staff can be dangerous.
Furthermore, dilution of adrenalin for intravenous use
is time-consuming and would delay treatment.
REMEMBER ½ ml i.m.
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Fact
Survey of radiologists’ knowledge regarding the management of severe
contrast-material-induced allergic reactions.
No radiologist gave the ideal response, but 41% provided an acceptable
administration route, concentration and dose. Only 11% knew which
concentration of epinephrine was available in their drug kit and/or crash cart
and which equipment would be required to administer it to a patient.
Lightfoot et al., Radiology 2009; 251(3):691-6
Conclusion:
Radiologists’ knowledge of epinephrine for the management of severe
contrast-material-induced allergic reaction is deficient.
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Guideline
1.1.1. Acute adverse reactions to iodinated
contrast media
Risk factors for acute reactions
Patient-related
Patient with a history of:
Previous moderate or severe acute
reaction (see classification above) to an
iodinated agent
Asthma
Allergy requiring medical treatment
Contrast-medium-related High-osmolar ionic contrast media
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Guideline
1.1.1. Acute adverse reactions to iodinated
contrast media
To reduce the risk of an acute reaction
For all patients
• Use a non-ionic contrast medium.
• Keep the patient in the Radiology Department for
30 min after contrast medium injection.
• Have the drugs and equipment for resuscitation readily available.
For patients at
increased risk of
reaction
• Consider an alternative test not requiring an iodinated contrast
agent.
• Use a different iodinated agent for previous reactors to contrast
medium.
• Consider the use of premedication. Clinical evidence of the
effectiveness of premedication is limited. If used, a suitable
premedication regime is prednisolone 30 mg (or methylprednisolone
32 mg) orally given 12 and 2 hours before contrast medium.
Extravascular
administration of
iodinated
contrast media
When absorption or leakage into the circulation is possible, take the
same precautions as for intravascular administration.
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Guideline
1.1.2. Acute adverse reactions to gadolinium
contrast media (non organ specific)
Risk factors for acute reactions
Patient-related
Patient with a history of:
Previous moderate or severe acute
reaction (see classification above) to an
iodinated agent
Asthma
Allergy requiring medical treatment
Contrast-medium-related
The risk of reaction is not related to the
osmolality of the contrast agent: the low
doses used make the osmolar load very
small.
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Guideline
1.1.2. Acute adverse reactions to gadolinium
contrast media (non organ specific)
To reduce the risk of an acute reaction
For all patients
• Use a non-ionic contrast medium.
• Keep the patient in the Radiology Department for
30 min after contrast medium injection.
• Have the drugs and equipment for resuscitation readily available.
For patients at
increased risk
of reaction
• Consider an alternative test not requiring an gadolinium contrast
agent.
• Use a different gadolinium agent for previous reactors to contrast
medium.
• Consider the use of premedication. Clinical evidence of the
effectiveness of premedication is limited. If used, a suitable
premedication regime is prednisolone 30 mg (or methylprednisolone
32 mg) orally given 12 and 2 hours before contrast medium.
Extravascular
administration
of iodinated
contrast media
When absorption or leakage into the circulation is possible, take the
same precautions as for intravascular administration.
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Guideline
1.1.2. Acute adverse reactions to gadolinium
contrast media (non organ specific)
The risk of an acute reaction to a gadolinium contrast agent is significantly
lower than the risk with an iodinated contrast agent.
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Guideline
2.1.3. Management of acute adverse reactions
First-line emergency drugs and instruments which should be
in the examination room
Oxygen
Adrenalin 1:1,000
Antihistamine H1 – suitable for injection
Atropine
β2-agonist metered dose inhaler
I.V. Fluids – normal saline or Ringer’s solution
Anti-convulsive drugs (diazepam)
Sphygmomanometer
One-way mouth “breather” apparatus
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Management of serious acute adverse
reactions to contrast media
Laryngeal edema
• Oxygen by mask (6 – 10 l/min)
• Intramuscular adrenalin (1:1,000), 0.5 ml (0.5 mg), repeat as needed
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Hypotension and bradycardia
(vaso-vagal reaction)
• Elevate patient’s legs
• Oxygen by mask (6-10 l/min)
• Atropine 0.6-1.0 mg intravenously, repeat if necessary after 3-5 min,
to 3 mg total
• Intravenous fluids: rapidly, normal saline or lactated Ringer’s solution
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Isolated hypotension
• Elevate patient’s legs
• Oxygen by mask (6-10 l/min)
• Intravenous fluid: rapidly, normal saline or lactated Ringer’s solution
• If unresponsive:
adrenalin: 1:1,000, 0.5 ml
(0.5 mg) intramuscularly, repeat as needed
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Generalized anaphylactoid reaction
• Call for resuscitation team
• Suction airway if needed
• Elevate patient’s legs
• Oxygen by mask
(6 – 10 l/min)
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Generalized anaphylactoid reaction
• Intramuscular adrenalin (1:1,000), 0.5 ml (0.5 mg) in adults.
Repeat as needed.
• Intravenous fluids
(e.g. normal saline, lactated Ringer’s)
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ESUR Guidelines
For further details