ACR Manual on Contrast Media: 2018 Updates

  1. Rosewinter Kodzwa, MBA, R.T.(R)(MR), HACP(CIHQ)

Rather than revise the entire American College of Radiology (ACR) Manual on Contrast Media yearly, the ACR only will revise certain chapters when necessary. In June 2018, it published numerous revisions to version 10.3, including:

  • refine language for better clarity

  • embolden previous recommendations with unequivocal rejections

  • offer a few new opinions

  • modify a few statistics

  • include more examples

  • increase provider readiness in the proper and safe administration of contrast media and the mitigation of extravasation risk

The same year, the committee also published the ACR contrast reaction cards (see Figure), a supplement to help technologists manage contrast-related adverse events.1 The supplemental guide to the manual, the ACR–SPR (Society for Pediatric Radiology) Practice Parameter for the Use of Intravascular Contrast Media, remained the same.2 The 2019 UK comparison manual, Standards for Intravascular Contrast Administration to Adult Patients, concluded that compliance with proposed standards should translate to high-quality care for patients who are referred to radiology departments.3 The changes made to the ACR manual in 2018 were borrowed from the UK manual, which is an international document tied to the ACR, Europe, and the U.S. Food and Drug Administration. It is well documented that compliance with proposed standards translate to high-quality care for patients who are referred to the radiology department.3

Figure
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    Figure

    American College of Radiology contrast reaction cards. The free cards were created as a supplement to the ACR Manual on Contrast Media to help health care providers manage contrast-related adverse events. Reprinted with permission from the American College of Radiology.

    Safe Injection of Contrast Media

    The chapter titled, Injection of Contrast Media, was changed to Safe Injection of Contrast Media. The current revision includes more references compared with the previous version, but the sources are older. A list of additional suggested readings is included, but the sources are from the 1970s. A workshop at the National Institutes of Health was created to explore concerns about the safety of gadolinium-based contrast agents and gadolinium retention. The workshop was cosponsored by the National Institutes of Health, the Radiological Society of North America, and the ACR.4

    Venipuncture and Mechanical Injection of Intravenous Contrast Media

    The revision included a change to the flow rate required when administering contrast media using a peripheral venipuncture site (eg, hand or wrist). The previous flow rate was 1.5 mL/second, whereas the new recommendation is to reduce the rate when feasible (eg, 1 mL/second to 2 mL/second). The technique related to using a power injector to prevent contrast media extravasation or an air embolism was restructured. Now, instead of adjusting the catheter if backflow of blood into the tubing was not obtained, backflow always should be noted, even in appropriately positioned intravenous (IV) lines. In both versions and in the ACR–SPR Practice Parameter for the Use of Intravascular Contrast Media, the use of a saline test flush remains a best practice, with the latest revision clarifying that the saline test flush can be performed by hand or once the tubing is connected to a power injector.1,2

    The previous version recommended monitoring the venipuncture site by palpation during the initial portion of the contrast medium injection, and if complications were not experienced in the first 15 seconds, the person monitoring the injection would exit the room before the scanning began. This guideline was refined to recommend starting the injection process through direct contact, following up via intercom or television system, and when feasible, notifying the patient of the presence of such systems. Communication between the technologist and the patient before, during, and after administration of contrast media has not changed, but the patient now is instructed to notify the technologist of any changes in sensation (eg, symptoms of increasing pain or swelling at the injection site).

    Air Embolism and Intraosseous Injections

    This revision placed special emphasis on watching for pain and swelling, more than doubling the referencing of these symptoms compared with the previous version. In addition, although large-volume venous air embolisms remain a potentially fatal but rare complication of IV contrast media injection, small-volume venous air embolisms now are considered clinically insignificant.

    A new recommendation was added regarding intraosseous infusions to consult the local trauma team for advice on how and whether to prime the line with anesthetic using local protocols. Intraosseous infusion allows rapid intravascular access for fluid and medication administration to critically ill patients without IV access, and this revision continues to support its low-reported complication rate.

    Contrast Reaction Cards

    The ACR contrast reaction cards (see Figure) summarize the steps to take when managing an acute reaction to contrast material and include detail on premedication and extravasations. The free cards outline multiple common and serious contrast reactions and are offered as an addition to the manual. The cards, about the size of a driver’s license, should be printed with the phone number the health system uses to activate a code blue and distributed to appropriate staff.5

    Extravasation of Contrast Media

    The previous range of reported incidence of IV contrast media extravasation related to power injection for computed tomography was 0.1% to 0.9%; that range was revised to allow a wider margin of 0.1% to 1.2%, and it was noted that although contrast injection rates have not been associated with the frequency of extravasation, extravasations can occur at low-and high-flow rates. However, extravasations are more common when injections are made into peripherally placed catheters. An interesting deletion on this topic is the removal of the previous opinion that permanent injury to extravasations are not limited to the immediately adjacent soft tissues (eg, the skin and subcutaneous tissues). The manual, however, holds to its initial opinion that rarely will a low-osmolality contrast media extravasation injury proceed to a severe adverse event. Although the most commonly reported severe injuries after extravasation of low-osmolality contrast media are compartment syndromes, the revision suggests they develop soon after an extravasation or from increased swelling, which sometimes occurs hours after the extravasation. The less commonly encountered severe injuries (eg, skin ulceration and tissue necrosis) can occur within hours or days of the extravasation event instead of as early as 6 hours after an extravasation event (as stated in the previous version).

    Evaluation

    The process of evaluating for extravasation combines improved and new recommendations, including that a responsible health care provider examine all patients who have experienced contrast material extravasation. The patients should be asked about symptoms of pain and paresthesias, after which a brief examination should be performed to assess:

    • extremity tenderness

    • swelling

    • erythema

    • active and passive range of finger motion.

    • perfusion

    Gadolinium-based magnetic resonance imaging contrast media toxicity is similar to or lower than other iodinated contrast agents; however, extravasations of these agents usually do not cause severe injury, likely because the total volumes of contrast material injected during magnetic resonance imaging are smaller.1

    Treatment

    The manual clarifies that many surgeons recommend initial use of cold compresses vs hot when treating for extravasation. Attempting to aspirate extravasated contrast medium through an inserted needle or angiocatheter now is not a recommendation because there is no consistent evidence of its success. Similarly, the use of hyaluronidase for managing extravasation of contrast material also is not recommended.

    Previously, instructions for outpatient treatment of extravasation included seeking additional medical care when symptoms worsened; now the manual spells out examples of those symptoms (eg, pain, swelling, and active or passive diminished range of finger motion). This clearer information provides health care professionals with specific indications of the symptoms they can expect when dealing with the injection and extravasation of contrast media.

    Surgical Consultation

    The revision includes new symptoms of worsening passive or active range of motion in the elbows, wrists, or fingers as well as the symptoms that require immediate surgical consultation after a severe extravasation injury. The manual maintains that the initial symptoms of a compartment syndrome might not be mild but adds that it might be absent. A clarification was added to the previous recommendation about avoiding alternate injection sites (eg, hand, wrist, foot, and ankle) because they were more likely to result in extravasation; it now notes that the use of these sites might be necessary if the more traditional locations are unavailable. The chapter on extravasation closes with a new recommendation stating that the referring physician should be notified only about extravasation events that are moderate or severe, but that all events should be documented.

    Conclusion

    Patient care interventions were highlighted in this cycle of revisions. More examples were provided for clarity and previous explanations were loosened, both of which could aid in writing better policies and procedures. The current revisions highlight the importance of good patient care skills in achieving safety outcomes for patients where contrast media use is concerned. The available contrast media resources when referenced together might help provide the reader a fuller understanding of the safe administration and treatment of contrast media extravasation. The responsibility of ensuring the safety of contrast media does not lie solely with contrast agent manufacturers; health care professionals also must do the best they can to safely administer contrast media and mitigate adverse events.

    Footnotes

    • Rosewinter Kodzwa, MBA, R.T.(R)(MR), HACP(CIHQ), previously staffed the American College of Radiology Drugs and Contrast Committee. She is a continuing education program reviewer for the American Society of Radiologic Technologists in Albuquerque, New Mexico, and can be reached at rkodzwa{at}asrt.org.

    References

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