Korean J Radiol.  2019 Jan;20(1):148-157. 10.3348/kjr.2017.0771.

Management of Adverse Reactions to Iodinated Contrast Media for Computed Tomography in Korean Referral Hospitals: A Survey Investigation

• Han S
• Yoon SH
• Lee W
• Choi YH
• Kang DY
• Kang HR

• KMID: 2429928
• DOI: http://doi.org/10.3348/kjr.2017.0771

Abstract

OBJECTIVE
To evaluate the current status of managing adverse reactions to iodinated contrast media (ICM) for computed tomography in referral hospitals in South Korea compared with hospitals in other countries.
MATERIALS AND METHODS
This survey investigation involved 59 Korean and 15 overseas hospitals using guideline-based questionnaires consisting of 24 items in 7 main categories related to managing adverse reactions to ICM.
RESULTS
Informed written consent with risk factor evaluation was appropriately performed in most of the Korean hospitals. There was considerable variability in assessing renal function across the hospitals; serum creatinine level was used as a reference in 76.4% of Korean hospitals. The Korean hospitals preferred a more stringent approach to determining normal renal function (p = 0.01), withholding metformin (p = 0.01), and fasting before ICM exposure (p < 0.001) compared with overseas hospitals. All the Korean hospitals had an emergency protocol and in-hospital system for adverse reactions to ICM. The Korean (87.7%) and overseas hospitals (100%) were similarly equipped with epinephrine (p = 0.332), but only 38.6% of Korean hospitals were equipped with a bronchodilator (p = 0.004). For patients with a previous hypersensitivity reaction to ICM, 62.3% of Korean hospitals pre-medicated with anti-histamine and corticosteroid according to the severity of the previous reaction, and changed the culprit ICM in 52.8%, while skin test was performed in 17%.
CONCLUSION
In general, Korean referral hospitals were well-prepared regarding informed consent, protocol, and an in-hospital system for managing adverse reactions to ICM. Nevertheless, there was considerable variability in details and management, thus requiring standardization by reflecting current guidelines.

Keyword

Guideline; Radiology practice; Emergency protocol; Drug allergy; Asthma

MeSH Terms

Asthma
Contrast Media*
Creatinine
Drug Hypersensitivity
Emergencies
Epinephrine
Fasting
Humans
Hypersensitivity
Informed Consent
Korea
Metformin
Referral and Consultation*
Risk Factors
Skin Tests
Contrast Media
Creatinine
Epinephrine
Metformin

Figure

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  Fig. 1 Distribution of tertiary and secondary referral hospitals in Korea.

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  Fig. 2 CT scans performed per day in hospitals.CT = computed tomography

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  Fig. 3 Distribution of number of ICM types used in hospitals.ICM = iodinated contrast media

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  Fig. 4 Cut-off level for serum creatinine (A) and eGFR (B) for contrast-enhanced CT scans in Korean hospitals.eGFR = estimated glomerular filtration rate

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  Fig. 5 Cut-off level for serum creatinine (A) and eGFR (B) for stopping metformin before contrast-enhanced CT scans in Korean hospitals.

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  Fig. 6 Distribution of duration of withholding metformin.Other answers included “Restart by physician,” “Restart at any time after CT scan depending on lab results,” etc.

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  Fig. 7 Contents of pre-scan fasting.

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  Fig. 8 Medical staff accompanying use of ICM for CT scanning during night-shift hours.Other answers included emergency department doctors, anesthetist, and intensive care unit doctors.

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  Fig. 9 Items included in emergency protocols for adverse reactions to ICM.Other answers included initial reporting system for adverse reactions.

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  Fig. 10 Items included in pre-scan protocols for patients with previous adverse reactions to ICM.Other answers included reconsideration of proceeding CT scan.

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  Fig. 11 Management of patients with previous adverse reactions to ICM in hospitals without protocols.

Reference

1. Bottinor W, Polkampally P, Jovin I. Adverse reactions to iodinated contrast media. Int J Angiol. 2013; 22:149–154. PMID: 24436602.

2. Bae K, Lee SM, Ha JY, Jeon KN, Moon JI, Choi BH, et al. Adverse drug reactions to CT contrast media in South Korea: incidence and risk factors. J Korean Soc Radiol. 2016; 75:41–48.

3. Bata P, Tarnoki AD, Tarnoki DL, Horvath E, Berczi V, Szalay F. Acute severe thrombocytopenia following non-ionic low-osmolarity intravenous contrast medium injection. Korean J Radiol. 2012; 13:505–509. PMID: 22778575.

4. UCSF Department of Radiology & Biomedical imaging Web site. CT and X-ray contrast guidelines. Updated July 20, 2017. Accessed September 17, 2017. https://radiology.ucsf.edu/patient-care/patient-safety/contrast/iodinated.

5. ACR Committee on Drugs and ContrastMedia. ACR manual on contrast media version 10.3. 2017. Accessed September 17, 2017. Available at: https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.

6. Korean Society of Radiology. Korean Academy of Asthma. KIoDSRM. Korean clinical practice guideline on adverse reactions of injectable iodinated contrast agent and gadolinium contrast agent for MRI, 2nd edition. Accessed September 17, 2017. Available at: http://www.allergy.or.kr/file/allergic2016.pdf. [Published 2016].

7. Korean Institute of Drug Safety & Risk Management imaging Web site. Drug safety information report trend. Accessed September 17, 2017. http://open.drugsafe.or.kr/trend/trend/Read.jsp?ntt_id=2003. Published 2016.

8. ESUR guidelines on contrast media. Version 8.1. European Society of Urogenital Radiology Web site. Accessed September 17, 2017. http://www.esur.org/guidelines/. Published 2013.

9. Lee J, Cho JY, Lee HJ, Jeong YY, Kim CK, Park BK, et al. Korean Society of Urogenital Radiology (KSUR). Korean Society of Radiology. Contrast-induced nephropathy in patients undergoing intravenous contrast-enhanced computed tomography in Korea: a multi-institutional study in 101487 patients. Korean J Radiol. 2014; 15:456–446. PMID: 25053905.

10. Davenport MS, Khalatbari S, Cohan RH, Dillman JR, Myles JD, Ellis JH. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material: risk stratification by using estimated glomerular filtration rate. Radiology. 2013; 268:719–728. PMID: 23579046.

11. Salpeter SR, Greyber E, Pasternak GA, Salpeter EE. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Cochrane Database Syst Rev. 2010; (4):CD002967.

12. Stang M, Wysowski DK, Butler-Jones D. Incidence of lactic acidosis in metformin users. Diabetes Care. 1999; 22:925–927. PMID: 10372243.

13. Oowaki K, Saigusa H, Ojiri H, Ariizumi M, Yamagisi J, Fukuda K, et al. [Relationship between oral food intake and nausea caused by intravenous injection of iodinated contrast material]. Nihon Igaku Hoshasen Gakkai Zasshi. 1994; 54:476–479. PMID: 8028954.

14. Wagner HJ, Evers JP, Hoppe M, Klose KJ. [Must the patient fast before intravascular injection of a non-ionic contrast medium? Results of a controlled study]. Rofo. 1997; 166:370–375. PMID: 9198507.

15. Webb JA, Stacul F, Thomsen HS, Morcos SK. Members Of The Contrast Media Safety Committee Of The European Society Of Urogenital Radiology. Late adverse reactions to intravascular iodinated contrast media. Eur Radiol. 2003; 13:181–184. PMID: 12541128.

16. Loh S, Bagheri S, Katzberg RW, Fung MA, Li CS. Delayed adverse reaction to contrast-enhanced CT: a prospective single-center study comparison to control group without enhancement. Radiology. 2010; 255:764–771. PMID: 20406882.

17. Abe S, Fukuda H, Tobe K, Ibukuro K. Protective effect against repeat adverse reactions to iodinated contrast medium: premedication vs. changing the contrast medium. Eur Radiol. 2016; 26:2148–2154. PMID: 26427700.

18. Park HJ, Park JW, Yang MS, Kim MY, Kim SH, Jang GC, et al. Re-exposure to low osmolar iodinated contrast media in patients with prior moderate-to-severe hypersensitivity reactions: a multicentre retrospective cohort study. Eur Radiol. 2017; 27:2886–2893. PMID: 27975150.

19. Lee SY, Yang MS, Choi YH, Park CM, Park HW, Cho SH, et al. Stratified premedication strategy for the prevention of contrast media hypersensitivity in high-risk patients. Ann Allergy Asthma Immunol. 2017; 118:339–344.e1. PMID: 28087383.

20. Yoon SH, Lee SY, Kang HR, Kim JY, Hahn S, Park CM, et al. Skin tests in patients with hypersensitivity reaction to iodinated contrast media: a meta-analysis. Allergy. 2015; 70:625–637. PMID: 25649510.

21. Behzadi AH, Zhao Y, Farooq Z, Prince MR. Immediate allergic reactions to gadolinium-based contrast agents: a systematic review and meta-analysis. Radiology. 2018; 286:471–482. PMID: 28846495.

22. Kanal E, Barkovich AJ, Bell C, Borgstede JP, Bradley WG Jr, Froelich JW, et al. ACR Blue Ribbon Panel on MR Safety. ACR guidance document for safe MR practices: 2007. AJR Am J Roentgenol. 2007; 188:1447–1474. PMID: 17515363.

23. Perazella MA. Current status of gadolinium toxicity in patients with kidney disease. Clin J Am Soc Nephrol. 2009; 4:461–469. PMID: 19201920.