Clinical procedure - contrast media intravenous (IV) administration

This document supplies information on the safe administration of contrast media via an intravenous cannula (IVC).

All healthcare professionals who give contrast media (CM) should be educated about and proficient in the administration of contrast, including how to manage side effects such as hypersensitivity, the potential impact on kidney function, and extravasation. This clinical procedure should be read in conjunction with the adverse reaction’s clinical resources listed above in ‘related pages’ and departmental policies.

Administration of IV contrast media should be in line with the relevant manufacturers’ product information and the therapeutic goods administration (TGA) requirements for contrast media, bottles/containers, syringes, and all other components of the contrast delivery system.^r

It is important to perform hand hygiene and, non-touch and aseptic non-touch techniques appropriately during contrast preparation and throughout contrast administration as per departmental policies and manufacturer’s guidelines.

Equipment type and content may vary between individual institutions, but the following should be available for this procedure:

• IV contrast injector
• IV contrast media (contrast media must be stored in a warming cabinet prior to procedure according to product guidelines)
• IV cannulation equipment
• Personal protective equipment (PPE)
• Emergency trolley (to treat contrast media reactions and/or cardiac/respiratory arrest)
• Extravasation management equipment (refer to Clinical procedure - extravasation management of intravenous anti-cancer therapies and contrast media).
• Contrast materials data sheet.
• Adverse reaction management guidelines for display in room e.g. ASCIA First Aid Plan Anaphylaxis Pictorial A3 Poster 2023.
• Management algorithm for extravasation of IV contrast media for display in room. Refer to eviQ resource ID 4358 Algorithm – extravasation management of IV contrast media.

Patient screening and education

1. Verify the patients identity as per Correct Patient, Correct Site, Correct Procedure Policy.
2. Ensure appropriate informed consent has been completed as per departmental policies.
3. Provide the patient with pre-procedure education including:
   • the IV contrast procedure and process for the imaging scan
   • risks and management of:
     • hypersensitivity reactions
     • kidney dysfunction (including cessation/recommencement of metformin if appropriate)
     • medical risk factors.
   • written information e.g. eviQ patient information IV contrast during radiation therapy imaging scans and RANZCR - Contrast Guideline - Patient Information Point of Care Tool.
4. Explain the side effects which may occur during the IV contrast injection to the patient.
   • Reassure the patient that the most common reactions to IV iodinated contrast will pass and only last a few minutes. For example, that shortly after administration, the contrast may cause:
     •  generalised warm/hot sensation throughout the body, usually starting in the throat which gradually moves down to the pelvic region
     • a metallic taste in the mouth
     • a sensation that they have passed urine.
   • Educate the patient on the signs and symptoms of severe and anaphylactic reactions or extravasation and to alert staff immediately if these occur. These can include:
     • difficulty breathing, facial or tongue swelling
     • redness on face, or anywhere on body skin rash
     • pain, swelling, redness, discomfort, burning or stinging at site of IV contrast administration.
5. Screen the patient for risk factors related to IV contrast administration. The following questionnaires may be useful:
   • RANZCR - Patient questionnaire.

   • European Society of Urogenital Radiology (ESUR) - Questionnaire for iodine-based contrast media administration.

6. Assess screening responses and start appropriate risk management and prevention if required e.g. pre-hydration, cessation of medications, estimated glomerular filtration rate (eGFR) performed and checked.

Contrast administration preparation

1. Ensure all the equipment is readily available and accessible, including emergency trolley and extravasation management equipment.
2. Assess if the patient requires cannulation:
   • If the patient is already cannulated: ensure IVC patency as per departmental policies.
   • If the patient is not cannulated: cannulate the patient as per departmental policies.
   • If a Central Venous Access Device (CVAD) is available: assess if it is appropriate for IV contrast injection (e.g. compatibility with power injector) and follow departmental policies.
   • Consider the patient's position for simulation when assessing and choosing the cannulation site (e.g. if elbows will be bent), as well as the cannula size (according to the flow rate required for injection).
3. Position the patient in their simulation scanning position.
4. Prepare and assemble equipment for IV contrast administration.
5. Ensure patency of IVC when accessing and before IV contrast administration by checking:
   • for blood return
   • that no resistance is felt when flushing (manual or automated) with 0.9 % sodium chloride or other compatible fluid
   • that the planned flow rate is right for the needle gauge used
   • the cannula can manage the required pressure for examination.
6. Position the injector in a suitable location and allow for enough clearance for connecting line (consider the length of scan and location of cannula).
7. Ensure two health professionals (including the contrast administrator) with appropriate training and competency check the following as per departmental policies:
   • correct patient as per Correct Patient, Correct Site, Correct Procedure Policy
   • contrast type and volume
   • route of administration
   • administration time
   • expiry date of IV contrast media.
8. Prepare the contrast injector and connect to cannula as per manufacturer’s guidelines and departmental policies. Confirm:
   • the line is appropriately primed
   • air has been expelled from the syringe and line
   • the volume of contrast used is appropriate (consider accounting for volume in tube length)
   • all connections are checked and secured.
9. Set the contrast injector flow rate as per departmental policies.
10. Check that there is enough line to account for couch movement during the scanning procedure and IV contrast administration without pulling at cannula.

Contrast administration

1. Ensure the emergency trolley and extravasation management equipment is readily available and any pre-procedure actions have been taken as per risk assessment. The patient must be visible to staff administering contrast and performing the scan at all times.
2. Perform a secondary time-out to check :
   • correct patient as per Correct Patient, Correct Site, Correct Procedure Policy
   • IV contrast volume
   • flow rate
   • injection timing (including any time delays) as per departmental policies.
3. When the radiation therapist(s) are ready to scan, they will inform the IV contrast administrator when to inject the contrast or, if using bolus tracking, when the automatic injection will occur.
4. Ensure the patient is aware that the contrast injection is about to occur.
5. Inject the contrast as per manufacturer’s guidelines and departmental policies.
6. Monitor the patient during the contrast injection for any signs of extravasation, hypersensitivity, or other adverse reactions.
7. If the patient displays signs of a hypersensitivity reaction or extravasation, immediately cease the procedure, and follow appropriate management guidelines. Refer to eviQ Contrast media hypersensitivity reactions and/or eviQ Extravasation management.

1. The patient should be observed and monitored post-procedure for any signs and symptoms of hypersensitivity adverse reactions with cannula to remain in-situ for 30 minutes.
2. If no hypersensitivity reaction is noted and vital signs are within normal limits the cannula can be removed

Delayed hypersensitivity reactions and management

Patients should be informed and educated on the risks, and signs and symptoms, of delayed hypersensitivity reactions. Patients should be instructed to ring Triple Zero (000) or IMMEDIATELY go to the nearest hospital Emergency Department if they have a delayed reaction.

Written information can be useful for patients e.g. 

• eviQ patient information IV contrast during radiation therapy imaging scans.
• RANZCR - Contrast guideline - Patient information point of care tool.

Hydration

Patients at high risk of renal adverse events should be educated on the importance of being well hydrated before and after contrast media administration. For more information refer to the eviQ Contrast media renal adverse events resource.

Metformin recommencement

For patients that have temporarily ceased metformin provide relevant information on recommencement. For more information refer to eviQ Contrast media renal adverse events resource.

Document the procedure in the patient’s medical record. Include:

• pre-procedure assessments and any measures taken
• any adverse reactions and management
• follow-up care needed (e.g. recommencement of metformin).

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History relating to ID 427 - Contrast administration for radiation therapy simulation scans:

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