Clinical procedure - intravenous (IV) contrast administration for radiotherapy simulation scans

This document provides information on the clinical procedure for the administration of intravenous (IV) contrast for radiotherapy simulation scans. Only health care professionals who have attained competency in intravenous cannulation and administration of contrast as per institutional guidelines should perform the included procedures. This document should be used in conjunction with expert clinical judgement and with individual institutional guidelines or policies.

The health care professional administering IV contrast (IV contrast administrator) should follow the relevant national and local institutional guidelines for the safe administration of IV contrast. The IV contrast administrator should be trained and competent in the relevant procedures including intravenous cannulation, IV contrast administration, the recognition of contrast media reactions, appropriate management, and resuscitation procedures including basic life support and have rapid access to staff competent in advanced life support. Administration of IV contrast should be in line with the relevant manufacturers’ product information and the TGA requirements including the contrast media, bottles/containers, syringes and all other components of the contrast delivery system.^r

Non-vascular administration of contrast media (e.g. oral contrast) also has a risk of adverse events including hypersensitivity anaphylactic reactions. For information on hypersensitivity reactions please see Contrast administration for radiotherapy simulation scans.

• IV contrast injector
• IV contrast media
• IV cannulation (IVC) equipment as per institutional guidelines
• Personal protective equipment (PPE) as per institutional guidelines
• Emergency trolley must be readily available as per institutional guidelines
• Extravasation management equipment must readily available (see link to Clinical procedure - Management of extravasation during intravenous contrast administration for radiotherapy simulation scans)
• Contrast materials data sheet must be readily available

Patient risk assessment and education

1. Verify patient identity per Correct Patient, Correct Site, Correct Procedure Policy.
2. Educate patients about the IV contrast procedure and process for the planning scan.
3. Ensure the appropriate pre-procedure patient education, risk assessment and informed consent for an IV contrast procedure has been completed (written or verbal as per institutional guidelines) including:
   • Patient has been provided with appropriate information regarding IV contrast (e.g. Link to RANZCR - Patient information point of care tool).
   • Patient has been educated on the need for risk determination and management regarding
     • hypersensitivity reactions
     • renal risk factors (including cessation/recommencement of metformin as appropriate)
     • medical risk factors.
   • Patient has completed a risk assessment. For example
     • RANZCR - Patient questionnaire point of care tool
     • ESUR - Questionnaire for iodine-based contrast media
     • ESUR - Questionnaire for gadolinium-based contrast media
   • A health professional has assessed risk assessment responses (e.g. Link to RANZCR - Practitioner questionnaire assessment point of care tool).
4. Explain the side effects which may occur during the IV contrast injection:
   • Reassure the patient that the most common reactions to IV contrast will pass and only lasts a few minutes. For example
     • that shortly after infusion, the contrast may cause a 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. For example
     • difficulty breathing
     • facial swelling
     • 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. Ensure appropriate adverse reaction prevention and risk management actions have been taken if required e.g. pre-hydration, cessation of medications, eGFR performed and checked etc.

Equipment preparation

1. Ensure all equipment is available including emergency trolley/extravasation management equipment.
2. Ensure injector battery is charged and plugged in (if required).
3. Ensure two health professionals with appropriate training and competency check dose and expiry date of IV contrast as per institutional guidelines.
4. Warm the contrast in a warming cabinet (ideal warming cabinet temperature: 37°C) prior to procedure according to product guidelines.
5. Assess if patient requires cannulation:
   • If Central Venous Access Device (CVAD) available
     • Assess if appropriate for IV contrast injection as per institutional guidelines. 
     • If CVAD will be used, follow institutional guidelines for contrast administration.
   • If patient already cannulated, ensure IVC patency
     • Use PPE per institutional guidelines.
     • Before IV contrast administration check for blood return and no resistance is felt when flushing with 0.9% sodium chloride or other compatible fluid.
   • If patient is not cannulated
     • Cannulate the patient as per institutional guidelines.
6. Once the patient is cannulated, the radiation therapist (RT) positions the patient in the simulation scanning position with relevant markers and equipment as per institutional guidelines.

Contrast preparation

1. Using PPE and following an aseptic technique in line with your local policies and procedures, prepare and assemble equipment for IV contrast administration.
2. Ensure patency of IVC when accessing and before IV contrast administration by checking:

• for blood return
• no resistance is felt when flushing with 0.9 % sodium chloride or other compatible fluid.

3. Position injector in an appropriate location. For example:

• Behind gantry ­- if patient is being scanned arms on chest or by sides.
• In front of gantry - for pelvis and head & neck patients.

4. Turn injector ON.
5. Remove syringe from pack (do not touch tip) and place into injector as per institutional guidelines.
6. Push plunger forward until all air evacuated.
7. Attach low pressure connecting tube ensuring all connections are tight.
8. Open contrast bottle and draw up using U shaped tube, and fill syringe until required volume plus an extra 3mLs has been drawn allowing for tube length.
9. Expel air from line.
10. Prime the line, ensuring all air is expelled.
11. Attach line to patient cannula.
12. Contrast administrator and RT to check that there is enough line to account for couch movement during the scanning procedure and IV contrast administration.
13. Set flow rate per institutional guidelines.

IV contrast administration

1. Ensure emergency trolley and extravasation management equipment is readily available and appropriate pre-procedure actions have been taken as per risk assessment.
2. When the radiation therapists are ready to scan they will inform the qualified IV contrast administrator (e.g. nurse/RT/medical officer) when to inject the contrast or, if using bolus tracking, when the automatic injection will occur.
3. Check the display parameters and that the correct volume of contrast to be administered, flow rate and timing has been set (including any time delays) as per institutional guidelines.
4. Inject the contrast as per manufacturer’s guidelines.
5. During the contrast injection ensure the patient is monitored to ensure contrast is being injected correctly and assess for any signs of extravasation or adverse reaction.  
6. If patient has an anaphylactic reaction or extravasation immediately cease the procedure and follow appropriate management of these.

Assessment of adverse reactions

Immediate hypersensitivity adverse reactions

Immediate hypersensitivity adverse reactions resulting in anaphylaxis may be mild, moderate or severe.

The following table on immediate hypersensitivity anaphylactic reaction classification and signs and symptoms are based on RANZCR guidelines:^r

For further information see link to RANZCR - Iodinated contrast media guidelines .

Extravastion

Signs and symptoms of extravasation include pain, swelling, redness, discomfort, burning or stinging at site of IV contrast administration.

Management of adverse reactions

Immediate hypersensitivity adverse reactions

The management of anaphylactic hypersensitivity reactions is based on the severity of the reaction. A delay in the initiation of treatment such as adrenaline can result in deterioration and death of the patient.

Moderate to severe anaphylactic reactions can be life threatening and should be considered a medical emergency. In an emergency follow institutional policies and procedures.

Example management or anaphylaxis point of care tools:

• RANZCR -  Anaphylaxis point of care tool - Recommended treatment regimen for management of anaphylaxis in a radiology suite
• RANZCR - Adverse reaction point of care tool - Treatment of adverse reaction to iodinated contrast media – Drugs and equipment

For additional information about hypersensitivity reaction management see link to RANZCR - Iodinated contrast media guidelines .

Extravastion

For information about extravasation management read Management of extravasation during intravenous contrast administration for radiotherapy simulation scans.

1. The patient should be monitored with cannula in-situ post procedure for the signs and symptoms of a hypersensitivity adverse reaction. The minimum time for observation is based on individual patient risk category as per the pre-procedure risk assessment (e.g. at least 15 minutes for low risk and at least 30 minutes for high risk patients^r).
2. If no hypersensitivity reaction is noted and vital signs are within normal limits the cannula can be removed.
3. Equipment should be disposed of as per institutional guidelines.

Delayed reactions and management

Patients should be educated on the risks, and signs and symptoms, of delayed reactions. Patients should be instructed to IMMEDIATELY go to the nearest hospital Emergency Department or contact their doctor or nurse if they have any of the following:

• difficulty breathing
• facial swelling
• tongue swelling
• redness on face, or anywhere on body
• skin rash.

Link to RANZCR - Patient information point of care tool.

Metformin recommencement

• Link to RANZCR - Letter to referring doctor regarding metformin cessation.

For further information on metformin and contrast media see link to RANZCR - Iodinated contrast media guidelines (Section 2.8).

In the patient’s medical record document the contrast procedure including any:

• pre-procedure assessments and actions,
• adverse reactions, and
• follow-up care actions required (eg. recommencement of metformin).
  • Link to RANZCR - Letter to referring doctor regarding metformin cessation.
  • To read more about metformin and contrast media see Section 2.8 in RANZCR - Iodinated contrast media guidelines.

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