contrast reaction?

[specepic]

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I am curious to get other peoples opinions on this...

on Friday afternoon, about 5-10 minutes after the patient's procedure the postoperative nurse came in to the fluoroscopy suite, when I was in the middle of my next case, and tell me the patient was reporting hives spreading across her chest and up to their face and also developing some "lip tingling". because I did not place an IV in this patient ( I usually do not for lumbar procedures) we did that right away of course and I gave her some IV Benadryl. I did not give epinephrine because she was not having any respiratory symptoms at all and denied any throat or tongue symptoms. her vitals were stone cold normal.

anyway, the Benadryl worked very nicely, we gave her second dose after a while just for good measure as she wasn't sedated at all from the first.

I am curious as to whether anyone would have sent her home on prednisone or given an injection of steroid in her deltoid or thigh "for the road". She looked so good after the Benadryl I recommended she continue oral Benadryl at home for the next 24 hours and call me with any problems. part of my rationale for not giving additional steroid is I just gave her 15 mg of dexamethasone in her epidural space.

opinions/comments/questions?

This is the first time I have seen a potential contrast reaction ( never saw one in residency, fellowship, or in 2 years of practice-- which of course I had just told a patient that very morning in clinic). I suppose other possible explanations could be reaction to preservatives? delayed lidocaine reaction? would a steroid flush from dexamethasone happen this fast? This was her second epidural and the first also used Omnipaque without problems ( Depo-Medrol for first injection, interlaminar)

 

[lobelsteve]

Sounds like a classic mild allergy to an agent injected.

I believe she has developed an allergy to the contrast or the steroid.
Patch testing is the only way to determine what caused this.

Attached are 2 PDF's, 1 for each possibility.

Now class, everyone take a minute to review with your staff the Rosenthal article for Emergency Protocols for the Spinal Injectionist

 

[Ducttape]

its a difficult situation.

in the ED setting, when a patient exhibits significant symptoms, such as any respiratory symptoms, some will make a cogent argument that those individuals should be observed in a hospital setting for 23 hours, as there is a significant risk for rebound effects 4-6 hours after the initial symptoms develop.

with just topical symptoms, it seems prudent that patient should be observed at least an hour or two, and that patient should be discharged under the direct supervision of someone who can contact EMS in case any symptoms develop in the next 24 hours.

 

[PinchandBurn]

did you use local anesthetic in the injectate?

Although you likely did not reach 'toxic' doses, some people can be sensitive to it and get peri-oral paresthesias as you suggested. So perhaps it was the local.

However, the hives suggest more of a contrast allergy. But never heard of peri-oral numbness w/ contrast allergy, it's more airway edema,etc I would have thought.

 

[BushDoc20]

i was in south australia a few days ago and was hanging out with my dad who is a senior radiographer at one of the northern suburbs hospitals and was watching him do a CT abdo with contrast when i pointed out to him the start of a massive seizure...he took no notice of it because he's had a few with a muscle jerk reaction....that is until we were trying to resus this guy ...massive tonic clonic seizure, temp 41C, massive rash all over his torso and no palpable pulse ...being the 1 of 2 doctors on site, i had every radiographer in the room. it took 4 defib attempts, 7 rounds of epi and adrenaline, pacing pads and a near 10mins of CPR to get this guy back....amazingly he has no neuro deficits. needless to say we slapped a big ALLERGY sticker on his chart and handed him a medic-alert form all filled out by me and told him go get is made up and wrote a note to his GP and on a scrap piece of paper "allergy to radio-opaque contrast - anaphalatic reaction"

 

[mdvol]

I have a lady who gets only peri-oral numbness and edema from contrast. I found out the hard way obviously by giving her contrast only to have her tell me after the fact - she denied allergy prior to injection - that the same thing happened with a CT study. No hives, no respiratory issues but onset was very fast and i only used about 1/2 to 1 ml of omnipaque 240.