Contrast reaction

[NJPAIN]

What is your protocol for premeditation in patients with prior IV contrast reaction?
Are you premedicating even those with "mild" (itching, few hives)? Are you premedicating regardless of type of injection and volume of contrast ? Are you using iv premed if contrast reaction not previously recognized despite literature indicating that steroids need to be administered 4-6 h prior to contrast exposure for maximum effect?

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[emd123]

I just give Gad. But when I did ER (11 yrs), and we really needed a ct with contrast (giving 50cc Omnipaque vs 1-2cc in Pain) we'd give 50 mg Benadryl IV and 125 mg of solumedrol a few minutes prior. 99% of patients with acute anaphylaxis in progress, that's what you're going to give them anyways (and maybe epi, too). It's the Benadryl that's doing 99% of the work. The steroid onset is hours, vs minutes for Benadryl or epi (seconds). Generally though, I don't pre-medicate, I just give gad, or if they're unsure whether their allergy was to iodinated vs gad, I just give no contrast at all and consent as to the higher risk of wet tap which outweighs the risk of death by anaphylaxis and airway closure, which I've seen happened once despite the most aggressive treatment (was a patient that ended up having mast cell dysfunction and prone to horrendous anaphylaxis). Note: the recent multi-society guidelines on steroid injections on another thread, agrees this is okay, if history of anaphylaxis (not giving any contrast at all).

Another option is prednisone 60mg po and Benadryl 50 mg po, 1-2 hr before, or Benadryl 50 mg IM/depomedrol 80 mg IM 30 min prior.

It's 6 of one, half dozen of the other, but getting Benadryl on board is most important for immediacy, then having the steroid on board for the hours after. Then you have to ask, do you have the patient continue the Benadryl and steroids for a couple days after since Benadryl wears off in 6 hours, but the contrast will hang around much longer while the steroids haven't yet kicked in. Remember, if someone is truly anaphylactic, it doesn't take much of a substance to kill them (bee venom, just 0.01 cc or so).

If someone's truly anaphylactic to something, it's usually best just to find an excuse not to give it, for an elective procedure. If it's a bogus ("I felt flushed" or "my body got warm") pseudo reaction, it probably doesn't matter what you do.

 

[lobelsteve]

Specific Recommended Premedication Regimens

Several premedication regimens have been proposed to reduce the frequency and/or severity of reactions
to contrast media.

Elective Premedication
Two frequently used regimens are:
1. Prednisone – 50 mg by mouth at 13 hours, 7 hours, and 1 hour before contrast media injection, plus
Diphenhydramine (Benadryl ® ) – 50 mg intravenously, intramuscularly, or by mouth 1 hour before
contrast medium [12].
or
2. Methylprednisolone (Medrol ® ) – 32 mg by mouth 12 hours and 2 hours before contrast media
injection. An anti-histamine (as in option 1) can also be added to this regimen injection [34].
If the patient is unable to take oral medication, 200 mg of hydrocortisone intravenously may be
substituted for oral prednisone in the Greenberger protocol [35].

Emergency Premedication
(In Decreasing Order of Desirability)
1. Methylprednisolone sodium succinate (Solu-Medrol ® ) 40 mg or hydrocortisone sodium succinate
(Solu-Cortef ® ) 200 mg intravenously every 4 hours (q4h) until contrast study required plus
diphenhydramine 50 mg IV 1 hour prior to contrast injection [35].
2. Dexamethasone sodium sulfate (Decadron ® ) 7.5 mg or betamethasone 6.0 mg intravenously q4h
until contrast study must be done in patent with known allergy to methylpred-nisolone, aspirin, or
non-steroidal anti-inflammatory drugs, especially if asthmatic. Also diphenhydramine 50 mg IV 1
hour prior to contrast injection.
3. Omit steroids entirely and give diphenhydramine 50 mg IV.
Note: IV steroids have not been shown to be effective when administered less than 4 to 6 hours prior
to contrast injection.

http://www.acr.org/quality-safety/resources/~/media/37D84428BF1D4E1B9A3A2918DA9E27A3.pdf/

Page 9 (13/128)

Also a good read on preceding pages regarding allergies and the uselessness of asking about shellfish.

 

[Ducttape]

i love asking about shellfish. you can get some decent restaurant recommendations as to good places to get lobsta

 

[SSdoc33]

i havent seen a true contrast allergy in the 15000 or so injections ive done. never have premedicated. 1-2 ml extravascular is not gonna do it, IMHO

 

[NJPAIN]

i havent seen a true contrast allergy in the 15000 or so injections ive done. never have premedicated. 1-2 ml extravascular is not gonna do it, IMHO

Did intercostal injection last week left side fifth rib. 37 yo post thoracotomy pain after repair aortic coarctation.Previous itching and mild rash with contrast CT, half doz CT with contrast previously with no reaction. After 1ml contrast and 2ml local steroid develops intense left chest heaviness. Unrelenting. Sat and hemodynamics stable. To ED - no pneumo, no MI. Their diagnosis- contrast reaction.

 

[emd123]

Did intercostal injection last week left side fifth rib. 37 yo post thoracotomy pain after repair aortic coarctation.Previous itching and mild rash with contrast CT, half doz CT with contrast previously with no reaction. After 1ml contrast and 2ml local steroid develops intense left chest heaviness. Unrelenting. Sat and hemodynamics stable. To ED - no pneumo, no MI. Their diagnosis- contrast reaction.

It only takes a few molecules to get the reaction if they're truly anaphylactic. It doesn't take long for an airway to close from anaphylaxis & angioedema, and if you don't have epi and Benadryl around it can be scary as ****.

 

[freddydpt]

I've seen lots of contrast reactions during radiology residency. In fact my very first day of radiology residency I was literally pulled in by the arm by a CT tech panicking and the patient turned out to have a contrast reaction with pulmonary edema. Gave lasix and epi and wheeled him personally to the ER. That was a fun first day.

 

[SSdoc33]

has anybody here seen a true anaphylactic reaction with a spine procedure? id like to hear their story if so.

 

[NJPAIN]

I've seen lots of contrast reactions during radiology residency. In fact my very first day of radiology residency I was literally pulled in by the arm by a CT tech panicking and the patient turned out to have a contrast reaction with pulmonary edema. Gave lasix and epi and wheeled him personally to the ER. That was a fun first day.

freddy
Would you expect to see bronchospasm and no rash or itching?
Would you expect to see a moderate to severe reaction in someone who had multiple prior IV studies with only the most recent resulting in mild rash and pruritus?

 

[freddydpt]

First question... Yes, you can definitely see the bronchospasm with no rash or itching. I saw it all the time when I covered contrast after hours as a resident. 99% of the time patients had a baseline of asthma and contrast just caused a brief flare.
Second question... I have heard of that scenario, usually in an "oops, I gave them contrast by mistake" scenario. We would watch those patients for 30 minutes after the injection. Can I explain it? Yes... but not a great explanation. I think the body has an allergic milieu. Asthmatics know that their allergies are much worse in pollen season, for example. Also, many patients are on chronic or chronic/intermittent antihistamine therapy that can change their allergic reaction on any given day.

 

[Ducttape]

a person might have a moderate to severe reaction after having little to few symptoms. this is classically seen in patients with food allergy. an oral antigen taken in the context of a full meal may only cause mild tingling of the lips, but by itself with no other substance to interfere with absorption might cause a full anaphylactic reaction.


bronchospasm represents histamine and fluid release in the lungs. rash or itching implies mast cell degranulation and systemic symptoms other than the lungs. you can clearly see bronchospasm without itching or rash.

 

[emd123]

a person might have a moderate to severe reaction after having little to few symptoms. this is classically seen in patients with food allergy. an oral antigen taken in the context of a full meal may only cause mild tingling of the lips, but by itself with no other substance to interfere with absorption might cause a full anaphylactic reaction.


bronchospasm represents histamine and fluid release in the lungs. rash or itching implies mast cell degranulation and systemic symptoms other than the lungs. you can clearly see bronchospasm without itching or rash.

And you can see airway angioedema and closure alone, with no itching or rash

 

[pjuer]

has anybody here seen a true anaphylactic reaction with a spine procedure? id like to hear their story if so.

I did a caudal epidural without dye under fluoro several years ago, as the patient was allergic to IVP dye. Performed in office procedure room. Used kenalog, lidocaine and saline. Five minutes later patient complained of itching, nausea and developed hives. Gave 50 mg benadryl IV and epi SC. Pt went quickly into pulmonary edema then PEA. Called code and 911. PA-C came to start compresions and I began to intubate patient, when she grabbed the ET tube out of my hand and responded. Shipped to ER, and she re-arrested there and was again and resusciatated. Saw her back in the office two weeks later, back and leg pain much better. Never did any more procedures on her.

 

[lobelsteve]

I did a caudal epidural without dye under fluoro several years ago, as the patient was allergic to IVP dye. Performed in office procedure room. Used kenalog, lidocaine and saline. Five minutes later patient complained of itching, nausea and developed hives. Gave 50 mg benadryl IV and epi SC. Pt went quickly into pulmonary edema then PEA. Called code and 911. PA-C came to start compresions and I began to intubate patient, when she grabbed the ET tube out of my hand and responded. Shipped to ER, and she re-arrested there and was again and resusciatated. Saw her back in the office two weeks later, back and leg pain much better. Never did any more procedures on her.

Fluoro allergy?

 

[SSdoc33]

I did a caudal epidural without dye under fluoro several years ago, as the patient was allergic to IVP dye. Performed in office procedure room. Used kenalog, lidocaine and saline. Five minutes later patient complained of itching, nausea and developed hives. Gave 50 mg benadryl IV and epi SC. Pt went quickly into pulmonary edema then PEA. Called code and 911. PA-C came to start compresions and I began to intubate patient, when she grabbed the ET tube out of my hand and responded. Shipped to ER, and she re-arrested there and was again and resusciatated. Saw her back in the office two weeks later, back and leg pain much better. Never did any more procedures on her.

And if you had used the contrast, everyone would have blamed it on the contrast. My point exactly! Although pretty scary

 

[bedrock]

I did a caudal epidural without dye under fluoro several years ago, as the patient was allergic to IVP dye. Performed in office procedure room. Used kenalog, lidocaine and saline. Five minutes later patient complained of itching, nausea and developed hives. Gave 50 mg benadryl IV and epi SC. Pt went quickly into pulmonary edema then PEA. Called code and 911. PA-C came to start compresions and I began to intubate patient, when she grabbed the ET tube out of my hand and responded. Shipped to ER, and she re-arrested there and was again and resusciatated. Saw her back in the office two weeks later, back and leg pain much better. Never did any more procedures on her.

-----Preservative allergy----

I had a patient on whom I performed several cervical ESI with preservative-free kenalog.
After the MA pharmacy mess, (I never used them), I switched to brand name kenalog/Depo only, and sure enough, when she needed her next cervical ESI six months later, she promptly developed dyspnea within minutes and had to treat with O2, Benadryl, and Epi.

I never offered her any more procedures, either.

 

[emd123]

I did a caudal epidural without dye under fluoro several years ago, as the patient was allergic to IVP dye. Performed in office procedure room. Used kenalog, lidocaine and saline. Five minutes later patient complained of itching, nausea and developed hives. Gave 50 mg benadryl IV and epi SC. Pt went quickly into pulmonary edema then PEA. Called code and 911. PA-C came to start compresions and I began to intubate patient, when she grabbed the ET tube out of my hand and responded. Shipped to ER, and she re-arrested there and was again and resusciatated. Saw her back in the office two weeks later, back and leg pain much better. Never did any more procedures on her.

Was allergic to something, not dye, but previously attributed to dye. Something or one of the additives, you injected she was allergic to obviously

 

[clubdeac]

I gave a guy an S1 TFESI. Seconds after injecting the medication the patient started panicking saying something terrible was happening complaining of chest pain and SOB. I literally saw hives quickly crawl up his waist to his head. His bp dropped to 70/40. We flipped him over, injected benadryl and epi, gave him oxygen and called EMS. Fortunately he responded well. Freaked me out

 

[NJPAIN]

As a result of the episode with my patient the ASC will no longer allow contrast administration in anyone with prior contrast reaction of any type or iodine allergy regardless of premedication.