Treatment of Patients



VA PUGET SOUNDMEMORANDUM TX-52HEALTH CARE SYSTEMSEPTEMBER 2014SUBJECT: CLINICAL RADIOGRAPHIC CONTRAST ADMINISTRATIONEXECUTIVE SUMMARY: To establish policies and procedures for the safe administration of enteric, intravascular, and other contrast agents. This revision is made in order to cohesively address the medical indications and effects of contrast administration in accordance with radiological concerns, and best medical practice, and in order to establish a more uniform standard of practice for contrast administration.POLICY: It is the policy of VA Puget Sound Health Care System (VA Puget Sound) that radiographic contrast media is utilized appropriately and properly to optimize imaging studies and minimize risk to the patient. The purpose of this document is:To establish policies and procedures for the safe administration of enteric and intravascular (IV) contrast media for imaging studies throughout VA Puget Sound,To ensure appropriate screening of patients prior to diagnostic imaging studies that require contrast,To ensure that patients at risk for contrast reactions are appropriately premedicated,To guide management of patients who are on metformin,To guide management of patients at high risk of contrast nephropathy or other complications that may ensue from contrast reactions, andTo guide other medical considerations in the administration of intravenous contrast.PROCEDURES:Contrast Administration:Iodinated intravenous contrast agents which are frequently used for radiological diagnosis possess a small risk of reaction that can range in severity from minor to fatal. Diagnostic Imaging Service utilizes evidence based standards recognized in the radiology community for the safe and effective use of diagnostic and therapeutic techniques, performed by personnel with specific training and skills.Radiology physicians and radiological technologists in Diagnostic Imaging are authorized to administer contrast according to the protocols appropriate for each study during regular hours. Coverage for contrast reactions during working hours: As noted above, an attending radiologist or radiology trainee (resident or fellow) will be available in the hospital when contrast is administered, during normal operating hours, 8 am to 5 pm. Coverage for contrast reactions beyond normal, working hours: After normal working hours, when there is no attending radiologist or radiology trainee in the hospital, the radiological technologist will contact the ordering or admitting physician to inform him/her of pending contrast injection and to ensure that they are available should a complication arise. If the ordering or admitting physician is not available, then the physician on-call for the respective service shall be notified. Any hospital physician will be capable of managing a contrast reaction, if a reaction develops. In rare cases where no radiologist is available, and there is no other physician coverage available, the technologist may contact the emergency room physician for coverage. The technologist will not administer contrast at any time without physician coverage. The on-call attending Radiologist will be consulted, if these options are exhausted, and no coverage can be arranged.Laboratory Tests Prior to Iodinated Contrast Administration (Serum Creatinine and EGFR):All inpatients and emergency department patients receiving IV iodinated contrast will receive laboratory studies, including serum creatinine measurement within 24 hours prior to contrast administration.All patients with signs or symptoms of acute renal insufficiency, should have serum creatinine measurement within 24 hours prior to contrast administration. It should be noted that patients with acute renal insufficiency, serum creatinine is not an accurate measurement of renal function.All patients who are on metformin-containing medications, should have serum creatinine measurement within 24 hours prior to their imaging study. Further assessment of serum creatinine will be performed at the discretion or the ordering physician or primary service.Risk factors for contrast-induced nephropathy, as defined herein include: A patient history of “kidney disease” as an adult, including: renal tumor, renal transplant, prior renal surgery, or a prior diagnosis of acute or chronic renal insufficiency,Diabetes mellitus,Patients who are on chemotherapy for cancer,Hypertension requiring medical therapy, andAge greater than 60.Outpatients with known renal risk factors for contrast induced nephropathy (from the list delineated above) will require measurement of serum creatinine within 7 days prior to a diagnostic imaging procedure where contrast is to be administered. Other outpatients, with no risk factors, as described above, should have a serum creatinine within 30 days of the CT study.Additional studies, including repeat serum creatinine measurement may be requested at radiologists’ discretion.The radiological technologist will check the patient’s creatinine level and estimated GFR on the Contrast Worksheet. If the patient’s eGFR (not creatinine) is less than 60 mL/min/1.73m2, the radiologist will be consulted. After hours and during holidays and weekends, the University of Washington (UW) resident or attending radiologist will be consulted. For all high-risk patients with an impaired renal function less than 30 mL/min/1.73m2) requiring IV contrast, a Medical Consent form will be completed and signed by the either the ordering physician or by the radiology physician. The technologists are not authorized to obtain consent. It should be noted that elderly patients with reduced muscle mass (and thus reduced ability to make creatinine) can have a “normal” serum creatinine level in the presence of a markedly depressed glomerular filtration rate.Laboratory Tests Prior to Gadolinium-Based Contrast Administration (Serum Creatinine And eGFR):As with iodinated-contrast administrations, all inpatients and emergency department patients receiving gadolinium contrast will receive laboratory studies, including serum creatinine measurement within 24 hours prior to contrast administration.All patients with signs or symptoms of acute renal insufficiency, should have serum creatinine measurement within 24 hours prior to contrast administration. It should be noted that patients with acute renal insufficiency, serum creatinine is not an accurate measurement of renal function.Outpatients with known renal risk factors for contrast induced nephropathy (from the list delineated above) will require measurement of serum creatinine within 7 days prior to a diagnostic imaging procedure where contrast is to be administered. Additional studies, including repeat serum creatinine measurement may be requested at radiologists’ discretion.The radiological technologist will check the patient’s creatinine level and estimated GFR on the Contrast Worksheet. If the patient’s eGFR (not creatinine) is less than 30 mL/min/1.73m2, the radiologist will be consulted. After hours, during holidays and weekends the UW resident or attending radiologist will be consulted.For all patients with an impaired renal function less than 30 mL/min/1.73m2) requiring gadolinium-based contrast, a Medical Consent form will be completed and signed by the either the ordering physician or by the radiology physician. The technologists are not authorized to obtain consent.It should be noted that elderly patients with reduced muscle mass (and thus reduced ability to make creatinine) can have a “normal” serum creatinine level in the presence of a markedly depressed glomerular filtration rate.Metformin:Metformin is a biguanide oral antihyperglycemic agent used to treat patients with non-insulin-dependent diabetes mellitus. A significant adverse effect of metformin therapy and the intravascular (IV) administration of iodinated contrast media is the potential for the development of metformin-associated lactic acidosis in susceptible patients. There is no evidence of metformin-induced lactic acidosis in patients who are given the normal doses of gadolinium used for MRI studies (in the range of 0.1 to 0.3 mmol per kg of body weight).The following are recommendations for addressing patients on Metformin, for whom a CT scan with iodinated contrast is scheduled:Patients should undergo laboratory evaluation with a serum creatinine and eGFR within 24 hours prior to administering IV iodinated contrast media,Patients should receive instructions from the ordering provider before the resumption of metformin,Patients on metformin will receive a metformin information page (Attachment D),Certain co-morbidities are known to increase the risk of metformin-induced lactic acidosis (liver dysfunction, alcohol abuse, cardiac failure, myocardial or peripheral muscular ischemia, and sepsis),In patients with normal renal function and no known comorbidities, there is no need to discontinue metformin prior to intravenously administering iodinated contrast media, nor is there a need to check creatinine following the test or procedure. Metformin should however, be held for 48 hours after administration of iodinated contrast, andIn patients with multiple comorbidities (as described above) or with known renal dysfunction who apparently have normal renal function, metformin should be discontinued at the time of an examination or procedure using IV iodinated contrast media and withheld for 48 hours. The health care provider should be responsible for the decision to restart metformin, based on clinical evaluation and optional, additional laboratory evaluation, as ordered by the referring physician. Communication between the health care practitioner, and the patient will be necessary to establish the procedure for reassessing renal function and restarting metformin after the contrast-enhanced examination. Nephrogenic Systemic Fibrosis:Nephrogenic systemic fibrosis (NSF) is a fibrosing disease, primarily involving the skin and subcutaneous tissues but also known to involve other organs, such as the lungs, esophagus, heart, and skeletal muscles. This entity seems to develop only in patients with acute or severe end-stage renal disease who are exposed to gadolinium-based contrast agents (GBCA).Based upon current knowledge, it is estimated that patients with end-stage CKD (CKD Grade 5, eGFR < 15 ml/min/1.73 m2) and severe CKD (CKD Grade 4, eGFR 15 to 29 ml/min/1.73 m2) have a 1% to 7% chance of developing NSF after one or more exposures to at least some GBCAs. However, most patients who have developed NSF had end-stage kidney disease and were on dialysis at the time of exposure.In patients with acute kidney insufficiency, or with an eGFR < 30 ml/min/1.73 m2, the following precautionary measures are suggested:CT with contrast should be suggested to the clinician, if it is useful for the clinical indication. CT would particularly be suggested in an anuric patient with end stage renal disease.If a contrast-enhanced MR examination must be performed in a patient with end-stage renal disease on chronic dialysis, GBCA with higher reported rates of NSF should not be used, including: Gadodiamide (Omniscan? – GE Healthcare); Gadopentetate dimeglumine (Magnevist? – Bayer HealthCare Pharmaceuticals); and Gadoversetamide (OptiMARK? – Covidien). Instead, the following agents should be considered: Gadobenate dimeglumine (MultiHance? – Bracco Diagnostics); Gadoteridol (ProHance? – Bracco Diagnostics); and Gadobutrol (Gadavist? – Bayer HealthCare Pharmaceuticals). Newer agents are not well-supported due to the paucity of literature, although few, if any cases of NSF have been reported. These agents include: Gadofosveset (Ablavar? – Lantheus Medical Imaging); and Gadoxetic acid (Eovist? – Bayer HealthCare Pharmaceuticals).The lowest possible dose needed to obtain a diagnostic study is recommended whenever appropriate. GBCA-enhanced MRI examinations should be performed as closely before hemodialysis as possible, as prompt post-procedural hemodialysis, although unproven to date, may reduce the likelihood that NSF will develop. While it is possible that multiple dialysis sessions may be more protective than merely a single session, this possible incremental benefit remains speculative. Some experts recommend several dialysis sessions following GBCA administration, with use of prolonged dialysis times and increased flow rates and volumes to facilitate GBCA clearance. Peritoneal dialysis probably provides less potential NSF risk reduction compared to hemodialysis and should not be considered protective.Patients With Acute Renal Insufficiency – Iodinated Contrast: Acute renal insufficiency is defined by either: An absolute increase in serum creatinine of ≥ 0.3 mg/dl (≥26.4 μmol/l),A percentage increase in serum creatinine of ≥50%, orA reduction in urine output, defined as < 0.5 ml/kg/h for more than 6 hours. In the setting of acute renal insufficiency, iodinated, intravenous contrast should be avoided. In these cases, clinicians should be directed towards other studies. If contrast is administered, then aggressive hydration should be prescribed by the ordering physician. In these cases, patients should also sign a consent form for contrast administration.Patients With Chronic Renal Insufficiency – Iodinated Contrast:Assuring well-hydrated state is the most important factor in preventing contrast-induced nephrotoxicity (CIN). Evidence for reno-protective effect of other prophylactic measures such as N-acetylcysteine (Mucomyst) and sodium bicarbonate for IV contrast injections is weak; use of these compounds is optional and should not replace hydration. All patients should have free oral fluids encouraged up until the time of the CT scan. In patients with congestive heart failure (CHF), aggressive hydration should be performed only with caution. In all patients for whom hydration is planned, the technologist should inquire about a history of CHF. If a history is elicited, then this should be reported to the respective radiology physician or to the referring physician.Depending on the patient’s renal function (as outlined below), either an oral or intravenous hydration regimen can be given. Hydration can be performed at the further discretion of the radiology physician and the ordering physician. If patients without CHF are felt to be less optimally hydrated, more aggressive hydration may be performed. In addition, examinations should generally be obtained with the least amount of contrast necessary to obtain a diagnostic study.Suggested regimens for hydration are provided below:Oral regimen: 500 cc (16 oz.) of water over two hours prior to the imaging procedure, and500 cc of water over two hours after the imaging procedure.Note: Low-cal Gatorade (“G2”) can be substituted for water.Intravenous regimen:Inpatients: Normal (0.9%) saline at 1 ml/kg/hr for 12 hours before and 12 hours after contrast bolus.Outpatients or Same Day study: Normal saline at 1-2 ml/kg/hr for 3-6 hours before and after the contrast bolus.At radiology physicians’ discretion, additional boluses of saline or saline with bicarbonate may be performed.Hydration recommendations for patients with eGFR greater than or equal to 60 mL/min/1.73m2 (Stage 1 and 2 renal impairment): In these patients, there is no increased risk of CIN, therefore studies may be performed without specific precautions, and with the usual oral or intravenous hydration recommendations, as described above.Hydration recommendations for patients with eGFR 30-59 mL/min/1.73m2 (Stage 3 renal impairment):If risk factors for CIN are present as described above, intravenous hydration is recommended. If risk factors for CIN are not present, oral hydration is also an option in addition to intravenous hydration.Other precautions should be considered. For example, if possible, the dose of contrast should be reduced (e.g. a CT scan of the abdomen/pelvis should be performed with 100 cc or less; a CT scan of the chest should be performed with 70 cc or less).If available, non-contrast imaging or MRI should be considered, and should be suggested by the radiology physician to the ordering clinician.Other precautionary measures, such as hydration with sodium bicarbonate and N-acetyl cysteine can be considered, on an optional basis.Contrast administrations should be temporally separated, as much as possible, by at least 24 hours.For patients with eGFR 0-29 mL/min/1.73m2 (Stage IV renal impairment):Non-contrast or alternative imaging should be strongly advised to the ordering physician,IV hydration should be optimized,Contrast doses should be minimized, as described above,Other precautionary measures, such as hydration with sodium bicarbonate and N-acetyl cysteine can be considered, on an optional basis,Contrast administrations should be temporally separated, as much as possible by at least 24 hours,Written and verbal informed consent should be provided, andDialysis may be performed. The benefits of dialysis in decreasing the risk of CIN are not well established. In patients with chronic, end stage renal insufficiency who are on hemodialysis (not peritoneal dialysis), informed consent is unnecessary. This should generally be applied when patients have chronic, longstanding end stage renal insufficiency, are on hemodialysis, and are anuric. If the technologist is uncertain, consultation should be made with the ordering physician, primary service, or radiology physician.Administration of dialysis within 24 hours is optional and should be performed at the discretion of the ordering physician or managing clinical service. There is a potential, theoretical benefit of dialysis in alleviating the osmotic load, after contrast administration in severely oliguric or anuric patients, although this is not well-established by empirical data.Enteric Contrast Administration:The radiology physician will review the appropriateness of the radiological exam and will set protocol for the need for of enteric contrast. For CT or MR enterography, neutral attenuating/signal intensity contrast (such as Volumen) should be used, as delineated by the respective protocols for these studies.Radiologists and radiological technologists are formally trained in the use of enteric contrast agents. Under the direction of a radiologist, radiological technologists are permitted to order enteric contrast for inpatients or emergency department patients, in CPRS, and prepare and administer enteric contrast agents.As with intravenous contrast, the radiological technologist is responsible for documenting any adverse effects the patients may have from enteric contrast in VistA, under complications, and on the Contrast Worksheet (Attachment A).Ready-to-use (not requiring reconstitution or dilution) enteric contrast will be ward stocked and bar-coded. Reconstituted or diluted enteric contrast will be prepared by the pharmacy and labeled with the patient name, drug name, strength, volume, and a bar code. The expiration date will also be included on the label. All inpatient enteric contrast orders will be verified by a pharmacist. The nurse will administer enteric contrast for inpatients via the Bar Code Medication Administration (BCMA) system.Enteric contrast used within the Diagnostic Imaging Service for outpatients will be labeled with the drug name, strength, and volume, if not apparent from the container. Reconstituted or diluted enteric contrast will be labeled with the expiration date and time (not to exceed 24 hours).Type and volume of enteric contrast administered should be reported by the technologist performing each study.Screening And Treatment For Contrast Allergy:The predictive value of specific allergies, such as those to shellfish or dairy products, previously thought to be helpful, is now recognized to be unreliable. A significant number of health care providers continue to inquire specifically into a patient’s history of “allergy” to seafood, especially shellfish. There is no evidence to support the continuation of this practice.Patients who have had prior reactions to contrast administration are at risk for future reactions, with an approximately 5-fold increase in risk. For those patients that are indicated by the radiologist for pre-medication due to prior contrast reaction the following protocol would be followed: Prednisone 50 mg 13 hrs, 7 hrs and 1 hour prior to exam and Benadryl 50 mg 1 hour prior to exam. Patients may also receive famotidine 20 mg PO 1 hour prior to the study, on an optional basis, at physicians’ discretion. Examinations requiring premedication for possible contrast reaction should be scheduled to occur during weekdays between 8AM and 4PM.Patients who have had prior contrast reactions should undergo informed consent for future administrations of contrast.Treatment of Contrast Extravasation at The Injection Site:Contrast extravasation at the injection site is a complication occurring in less than 1% of peripheral venous contrast administrations (between 0.25 and 0.9% of examinations requiring administration of peripheral venous contrast). Fortunately, the large majority of contrast extravasations are self-limited events, requiring minimal management.All contrast extravasations should be reported by the technologist to the responsible physician (either a radiology physician or the respective ordering physician, as described above). Even small volumes of contrast extravasations can cause important clinical sequelae, including pain, skin ulceration, and compartment syndrome.Patients who are elderly, and unconscious patients are at increased risk of contrast extravasation at the injection site. Particular care should be used in these patients.If a contrast extravasation occurs, then the following should be performed:The injection should be stopped immediately and the contrast extravasation should be reported to the responsible physician.Optionally, patients may be monitored for 1-2 hours in the radiology department.In the case of severe contrast extravasations or severely symptomatic patients, patients may be transferred to the Emergency Department.In addition, an emergent or urgent consultation of the plastic surgery service may be performed in patients who are severely symptomatic, or in other situations where significant sequelae are suspected.The affected extremity should be elevated above the heart. Patients should be instructed to elevate the upper extremity whenever possible, above the heart during the subsequent 48 hour period.Cold compresses may be applied to the affected area to minimize edema. Occasionally, these may be optionally alternated with warm compresses as well.Patients should be instructed to visit the emergency department immediately if the following occur: skin blistering, increasing pain over time, paresthesias or other sensory symptoms distal to the area of extravasation, or other signs of altered tissue perfusion.RESPONSIBILITIES:Physician Duties:The Director of the Diagnostic Imaging Service is responsible for implementation of this policy. This responsibility is also shared with the Site Directors for CT and MRI, in their respective modalities.It is appropriate for attending radiologists to refer to published, national guidelines, including the ACR Manual on Contrast Media, and to use those guidelines on a discretionary basis, or in clinical settings that are not covered by this manual.The radiologists or radiology physician staff, including the attending radiologists and trainees, will be responsible for approving each request and protocoling each study, except in the setting of neuroradiology studies, which are governed by a separate set of protocols, not listed herein.The radiologist will determine, in conjunction with the referring physicians, when examinations are performed with contrast, and the route(s) of contrast administration (enteric and/or intravenous, etc.).The radiology physician dictating each study will document the amount of contrast, the type of contrast given, and the route of administration in the radiology report. During the hours of 8 am through 5 pm on weekdays, the in-house physician radiology staff will be responsible for monitoring and treating contrast reactions and contrast extravasations, and will be responsible for evaluating patients, except in instances when the respective code team is activated, or in instances when care is taken over by the admitting physician or other responsible physician.The radiology physicians will address any additional concerns raised by the technologists, and will interact with patients in other situations, on a discretionary basis. After hours, coverage for contrast reactions and extravasations should be provided by the ordering physician, or by the physician covering for the ordering service. In situations when no responsible physician is available, the emergency department physician should be notified for back-up purposes.A radiology attending physician will also be reachable by pager to answer technologist or clinician questions, and will be available for clinical consultation, and to read emergent studies between the hours of 5 pm and 6 pm on weekdays. After-hours physician coverage for consultation and interpretation of radiology studies will be provided remotely by the on-call resident physician at the University of Washington. In the event that the resident physician at the University of Washington is not available, remote coverage will be provided by the National Teleradiology Program (NTP) or by the on-call attending radiologist. For after-hours procedures requiring contrast administration, the exam will be protocoled by the University of Washington radiology resident on-call and faxed to the VA radiology department. (Neuroradiology examinations are excluded from this, however, and are protocoled in accordance with separate documents.) The radiology resident covering the VA hospital after-hours (from UW) will be available for consultation with the technologists regarding study protocols, questions about pre-medication, or other issues. For emergent or stat neuroradiology studies performed outside of normal working hours, interpretation will be provided by NTP. Emergent and after hours neuroradiology studies will follow the standard operating procedure (SOP) dated 9/24/2013 entitled, “After Hours Stat Neuroradiology Exams”. Life-threatening and other emergent situations will be addressed by the respective code teams of the hospital. If a contrast reaction develops, the physician who receives the technologists’ notifications and who assesses the patient will document their assessment in CPRS. In the case of resident physicians, CPRS notes should be co-signed by a radiology attending physician. No additional co-signature is needed for fellows.Technologist Duties:Technologists will be required to have annual competency evaluations documented in their competency folders. These competency evaluations will be completed by the chief technologist.The radiological technologist will notify the radiologist or other responsible physicians any time a contrast reaction occurs, regardless of how minor (e.g. hives) or major (respiratory difficulty, etc.). In the event of a life-threatening reaction or other life-threatening situation, the radiological technologist will initiate a Code Blue. In the event of a Code Blue in the MRI scanning area, after activating the code blue team, the technologist should immediately remove the patient from the MRI room, so that medical care can be provided expeditiously, outside of the MRI suite, and beyond the 5 gauss line.Symptomatic extravasations of IV contrast will be reported immediately to the radiology physician, when available. Extravasations will also be reported to the referring, or other responsible physicians, when the radiologists are not in-house. Contrast extravasations will also be documented by the technologists, in the patient’s electronic medical record.For each study, the technologist should indicate and clearly document the type, volume and route of contrast delivery in the “case edit” field in VistA. The radiological technologist will enter orders in CPRS for authorized clinician signature in cases where there is no appropriate lab value or lab order preceding the exam. For CT, a Contrast Worksheet for patients receiving iodinated contrast media (Attachment A) will be completed by the radiological technologist prior to each procedure. Technologists will also present all patients undergoing CT with a printed IV Contrast Patient Information (Attachment C). For each MRI study, an MRI worksheet will be completed by the technologists (Attachment B). Technologists will also give patients an opportunity to ask questions regarding scans and administration of contrast. Technologists may also, at their discretion, bring patients’ questions to the attention of the physician staff. When appropriate, technologists will bring any issues regarding protocoling, scanning, and patient care to the attention of the respective physician staff. Technologists will be responsible for reviewing patient medical record either in CPRS or via Health Summary printout for allergy, current lab values (creatinine, eGFR), and current medications with respect to metformin-containing medications. In the case of MRI, technologists will compete the relevant MRI safety form (Attachment B). For patients who are on metformin, the technologists will provide a metformin information page. (Attachment D). Technologists will ensure that the CT or MRI protocol has been reviewed and completed by a Radiologist for the examination. The technologist should document every allergic or allergic-like reaction to contrast that occurs, and place a flag on the respective patient’s record in CPRS. The technologists will also be responsible for familiarizing themselves with this policy.Technologists will also be familiar with the locations in which protocols for CT and MRI studies are stored.REFERENCES: VA Puget Sound memorandum, TX-10 Drug Distribution and Accountability, June 18, 2013.American College of Radiology (ACR) Procedure Manual on Contrast Media, Version 9, 2013.Current Topics from the Drug Information Center Vol. 33 (5); 2012.Medication package inserts for: Iohexol (Omnipaque?), iodixanol (Visipaque?), diatrizoate (Hypaque-Cysto?),Omnipaque?, Ultravist?, Visipaque?, Conray?, Prohance?, Magnevist?.RECISISSION: Memorandum TX-52 May 2013.FOLLOW-UP RESPONSIBILITY: Director, Diagnostic Imaging Service.EXPIRATION: Last work day of September 2016.MICHAEL J. MURPHY, FACHEDirectorAttachments:CT Contrast WorksheetMRI Contrast WorksheetIntravenous Contrast Patient InformationMetformin Information PageIODINATED CONTRAST WORKSHEETDate: _________________ Patient name/SS#: ________________________Procedure: [ ] CTRequesting Physician/Pager # _______________________Renal Function: DATE LABS ORDERED MUST BE: WITHIN 24 HOURS FOR ED/INPATIENTS, AND PATIENTS WHO ARE ON METFORMIN; WITHIN 7 DAYS FOR OUTPATIENTS WITH RISK FACTORS; AND WITHIN 30 DAYS FOR NO-RISK OUTPATIENTS Known Renal Risk Factors (circle all that apply): Age 60+; chronic or acute renal insufficiency; history of other kidney disease, including nephrectomy; diabetes; hypertension requiring medication; or cancer patients on chemotherapy.Creatinine (mg/dl)__________ eGFR: _________________ Date: __________Medication Reconciliation and Review: from discussion with patient and/or Health Summary: 1. Allergy: Radiologic contrast Yes / No Specify: ______________________ Foods, meds, asthma Yes / No Specify: ____________________Pre-medication for allergy: Yes / No Specify: ________________ 2. Medications: Metformin (Avandamet, Glucophage, Glucovance, Metaglys):Yes/No Specify: RADIOLOGIST ATTENTION NEEDED (circle applicable): eGFR < 60 or previous allergy.If patient has history of contrast allergy or has renal failure:Hydration given (circle): Yes / NoIf yes, specify regimen:PROTOCOL / RADIOLOGIST SIGNATURE: Supervising Radiologist:____________________________________Pager:____________________________________ (If after hours, indicate in-house physician overseeing administration of IV contrast) Radiological Technologist to complete the following: Protocol Performed: _____________________________________________________________________ IV Contrast (type, volume in ml, rate of administration:__________________________Enteric contrast (type, volume in ml): __________________________ If patient has history of allergies, was pre-medication administered? Yes / No / NA Comments/Complications:_________________________________________________ Radiological Technologist:_________________________________________________** TECHNOLOGIST MUST CONSULT WITH THE RADIOLOGY PHYSICIAN IF THERE ARE ANY ISSUES AND CONCERNS ABOUT ADMINISTERING CONTRAST. FAX NUMBER SEATTLE VA CT: 206-277-4340MRI CONTRAST WORKSHEETPatient Name / Last 4 of SS# / Age : __________________________ / _____ / _ Prior reaction to contrast administration? Yes / No If Yes, Specify_______________Known Renal Risk Factors (circle all that apply): Most recent eGFR<60, Renal Failure, Dialysis, Single Kidney, Renal Transplant, Renal Neoplasm, Diabetes Mellitus, Age 60+Labs (within 30 days for no-risk outpatients, 14 days for positive risk outpatients, and 24 hrs. for inpatients): If no adequate labs, order Cre/eGFR: Order #______________ Creatinine (mg/dl):___________ eGFR: __________ Date: __________ RADIOLOGIST ATTENTION NEEDED: LOW GFR! (circle if < 60 ml/min/1.73m2) Need for consent form? Yes / No A signed consent must be obtained for: eGFR < 30 ml/min/1.73m2 eGFR 30 to 59 ml/min/1.73m2 with Acute Renal FailureDialysis (Referring physician, Dr.___________________ contacted by __________________ to confirm patient has DIALYSIS SCHEDULED within 12 hours of Gad MR) Special GAD Instructions: Multihance _______ Half Dose? (GFR<30) ________ MRI TECHNOLOGIST ACTIONS:IV Gadolinium Contrast:_____ml Prohance / Multihance / Other (_________)If patient has history of allergies, was pre-medication administered? Yes / No / NA Comments/Complications: __________________________________________________ Radiological Technologist: ______________________________R.T. (R)(MR) If after hours: In-house physician contacted for contrast administration (Name): ______________MR PROTOCOL / RADIOLOGIST SIGNATURE: ___________________________** TECHNOLOGIST MUST CONSULT WITH RADIOLOGIST OR RESIDENT IF THERE ARE ANY ISSUES AND CONCERNS ABOUT ADMINISTERING CONTRAST **INTRAVENOUS CONTRAST PATIENT INFORMATIONYour doctor has requested that you have a special test that requires an injection of x-ray dye into your bloodstream. This dye shows up on x-ray film or CT scan images and helps the radiology doctors look deep into your body to look for evidence of disease.The dye is given through a needle or small plastic tube in a vein, usually on the inside of your elbow or back of your hand. These dyes are quite safe. However, any injection carries a small risk of harm at the injection site. There is a slight risk of injury to a nerve, vein, or skin, and/or the possibility of infection. Dyes can also occasionally produce more general reactions. Examples of a mild reaction to x-ray dyes include nausea, sneezing or hives. Uncommonly (less than one case in a thousand), a more serious reaction to the dye occurs such as breathing difficulty or kidney damage. The doctors and staff of this department are trained to treat these reactions. Very rarely (less than one case in 40,000) death occurs from the use of an x-ray dye. The risk of such a severe reaction is similar to that from an injection of penicillin.Certain patients are at higher risk for experiencing a reaction to the dye, and we may need to change our procedures to help balance these higher risks. If you have a history of any of the following illnesses, please notify the x-ray staff so that they can plan your examination correctly:Previous “allergic like” reaction to contrast materialActive asthmaMany or severe allergiesSevere heart diseaseCertain diseases (multiple myeloma, sickle cell disease, or pheochromocytoma)Kidney damage, especially when caused by diabetes mellitus (“sugar diabetes”).Age greater than 75Use of Metformin (Glucophage) for diabetesOther recent (48 hours) injection of contrast agentsYou have the right to refuse the examination and or the use of an x-ray dye. Alternative examinations without the use of an x-ray dye may be possible but may not be as complete or accurate as one with an x-ray dye. If you choose not to have this examination, please discuss other possible choices with your doctor.\s ................
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