ER doc order everything without contrast

[chudat]

Started this new gig telerad for private group covering a small regional hospital afterhrs. Been doing it for a couple months now. There is this ER doc, that orders al cross sectionals without contrast.

I.e. 14 yrs skinny child RLQ pain appy etc


Why? I've been putting impressions in my report specifically asking for IV contrast and she still doesnt order them.

How can I get her to change her practice guidelines when it comes to imaging orders.

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[EMhawkeye]

The radiology literature even shows contrast is over utilized.

 

[bravotwozero]

That may not work when trying to rule out appy in a skinny 14 year old. High chance of read coming back saying ‘appendix not visualized’

 

[Brigade4Radiant]

I guess it depends on the scanner my radiologist can show how big the appendix is without contrast in a lot of kids/men

 

[southerndoc]

@chudat have you tried calling the physician? That's probably going to have better effect than simply adding it to the report.

 

[WorkNoteEmergency]

That may not work when trying to rule out appy in a skinny 14 year old. High chance of read coming back saying ‘appendix not visualized’

There’s an argument that if you can’t see the appendix, very good chance it isn’t swollen and inflamed. Clinical correlation required of course and maybe not sufficient if the kid is screaming and throwing up. A few years ago I was navigating my way through a challenging RLQ pain in a skinny adolescent, forget the details leading up to my involvement, but I talked with the radiologist and he asked me to order a CT. I asked what kind of contrast and he said “none, I’ll be able to read it fine without any”. I almost fell over.

 

[GonnaBeADoc2222]

Started this new gig telerad for private group covering a small regional hospital afterhrs. Been doing it for a couple months now. There is this ER doc, that orders al cross sectionals without contrast.

I.e. 14 yrs skinny child RLQ pain appy etc


Why? I've been putting impressions in my report specifically asking for IV contrast and she still doesnt order them.

How can I get her to change her practice guidelines when it comes to imaging orders.

Why are you attempting to doxx this physician by putting their initials

 

[Brigade4Radiant]

When there was a contrast shortage the radiologists were telling us a lot of things other don't need contrast with the next generation CT scanners we got.

 

[BoardingDoc]

Why are you attempting to doxx this physician by putting their initials

While I agree the initials aren't necessary (and I've deleted them), I don't see this as an attempt to dox someone, rather than simply being somewhat careless.

Edit: I'm less sure about my original take based on the below reply to you.

 

[GonnaBeADoc2222]

Like most things to do with contrast (necessity, AKI, allergy) it is rooted in nonsense

 

[namethatsmell]

@chudat have you tried calling the physician? That's probably going to have better effect than simply adding it to the report.

Agreed. Talking to people privately in a non-threatening/accusatory manner is a timeless way to affect change. Or at least promote collegiality.

It's remarkable the foolish games folks will play inside a patient's medical record...ie chart wars...rather than just actually talking with each other.
A few months ago somebody tried to do that to me but I didn't engage. But it still blew up in the face of the initiating doc when the patient read their own chart (duh) and went after them.

Patient's chart isn't twitter or insta.

 

[chudat]

Why are you attempting to doxx this physician by putting their initials

It's my initials

 

[JacobMcCandles]

Contrast is overrated for most abdominal CTs. I’m convinced that every radiologist has their “lack of IV contrast” macro inserted into every CT without contrast.

 

[chudat]

Like most things to do with contrast (necessity, AKI, allergy) it is rooted in nonsense

Who's to say contrast isn't necessary? You're not the one having to read a noncon Ct belly in a skinny 14yr old and trying to locate the appendix.

In early appy the appy may not even be that dilated. What about tip appendicitis?

I briefly talked to this individual before in passing/over the phone. She's still ordering noncon on every Ct

 

[chudat]

Contrast is overrated for most abdominal CTs. I’m convinced that every radiologist has their “lack of IV contrast” macro inserted into every CT without contrast.

Sure in most Cts....but in a 14yr old rlq it could really help

 

[BoardingDoc]

It's my initials

You're saying you wrote "There is this ER doc, <my initials>, that orders cross sectionals without contrast"?

That makes literally zero sense.

 

[Janders]

I love looking at my own CTs; I’m a solid emergency radiologist but clearly not an actual radiologist. In my personal review of thousands of CTs… IV contrast is often quite helpful in a CT A/P. It, of course, depends on what you are looking for, and the patients age/anatomy/size. And while you usually/often find your pathology without it, I rather prefer having IV contrast on my belly scans when I’m looking for non-specific emergent badness. Even oral contrast is OCCASIONALLY helpful, for specific people/indications. I probably ask for oral contrast on <<2% of my scans, but it can be lovely when needed.

So why would one never order IV contrast? I had a former coworker that never used it aside from CTA PE or similar where it was absolutely required. Why? He noted marked increased turn around time leading the marked increase in LWBS / patient complaints, driven by inane needs for fresh BUN/Cr results on anyone getting any IV contrast (hospital policies very restrictive, labs often not done prior to MD eval), many issues getting IV access in patients for their scan (partially population related, partial newbie nurse skill related) requiring him to place IVs, and vociferous radiologists who would argue and complain about IV contrast dangers in any renal disease requiring a 2-4hr pre-hydration protocol, multi page signature forms for breast feeding women, etc. If he just ordered all his bellies as non-con r/o renal colic studies, they got done in <30 minutes and he found all the emergencies he needed to find and the entire department flowed better, people were happy, and he was happy and productive.

So that is my guess as to why the person you have noted avoids IV contrast. The system creates the output it was designed to give.

 

[JacobMcCandles]

Sure in most Cts....but in a 14yr old rlq it could really help

Hence, my use of the word ‘most’.

 

[Clean7795]

If the ER doc doesn't want to change their practice after speaking to them, then that's that. The issue is too small to bring to the ER director/dept head. Most rads just report it as limited and go on with their lives. In some places the rads unilaterally change the order (this can lead to friction between the departments).

Like most things to do with contrast (necessity, AKI, allergy) it is rooted in nonsense

Necessary probably isn't the right word, but there is added utility in a proportion of patients where contrast can help characterize the appendix, identify a small complex fluid collection, or exclude clinical mimickers of RLQ pain. One can argue this is mainly pertinent to the patient & surgeon, and negatively impacts ER workflow, but if you're going to CT scan a 14-year-old it is probably best to attempt the highest quality scan.

 

[Mbekweni]

Slick new study in JAMA from May 2023.

Key Points
Question What is the diagnostic accuracy of unenhanced computed tomography (CT) in patients admitted to an emergency department with abdominal pain?

Findings In this multicenter diagnostic accuracy study, unenhanced CT was approximately 30 percentage points less accurate than contrast-enhanced CT for diagnosing the cause of pain and identifying actionable secondary diagnoses.

Meaning In a general population of emergency department patients with abdominal pain, using unenhanced CT to avoid risks of intravenous contrast medium administration was associated with a large diagnostic penalty.

Diagnostic Accuracy of Unenhanced CT for Evaluation of Acute Abdominal Pain in the Emergency Department

This study attempts to determine the diagnostic accuracy of unenhanced abdominopelvic computed tomography using contemporaneous contrast-enhanced computed tomography as the reference standard in emergency department patients with acute abdominal pain.

jamanetwork.com

 

[Mbekweni]

And a review/analysis of the above article (paywall). Any academics with journal access want to summarize?

Intravenous Contrast in Computed Tomography Imaging for Acute Abdominal Pain

Shaish et al1 tested the diagnostic accuracy of unenhanced computed tomography (CT) scans by digitally subtracting contrast media and asking blinded radiologists (faculty and resident physicians) to interpret the unenhanced scans ordered in the emergency department for evaluation of acute...

jamanetwork.com

 

[Tiger26]

On the flip side, I order contrast on CTs as often as I can. I've seen misses before on both my patients and those of others, so I'm ok waiting the extra time for labs to come back.

 

[PianoMedic]

We have a point of care machine and use it liberally for creatinines to expedite patients to CT. It’s actually preselected in our abdominal pain orderset.

 

[MechEDoc]

Hence, my use of the word ‘most’.

The doc probably came from a different practice environment where almost no one got IV contrast. Not they're set in their ways.

The first place I worked (2015-16) would insist on IV, oral, and RECTAL contrast on skinny teens on appy rule outs. They'd override my orders all the time. I refused to order the rectal contrast and let the radiology department continue their malpractice on their own initiative.

 

[larpleston]

Could be that they got used to ordering everything noncon when there was a contrast shortage and radiologists were insisting on their ok for any non CTA contrast.

 

[Tenk]

Everyone here saying IV contrast is overrated clearly doesn’t read their own scans. Despite just making the image quality better, I’ve found numerous dissections that I could swear were gonna be kidney stones. If you’re gonna do a study, might as well make it the best.

 

[RustedFox]

Everyone here saying IV contrast is overrated clearly doesn’t read their own scans. Despite just making the image quality better, I’ve found numerous dissections that I could swear were gonna be kidney stones. If you’re gonna do a study, might as well make it the best.

For real.
It takes what, 2 more minutes to push the contrast?
KTHXBYE.

 

[gutonc]

Everyone here saying IV contrast is overrated clearly doesn’t read their own scans. Despite just making the image quality better, I’ve found numerous dissections that I could swear were gonna be kidney stones. If you’re gonna do a study, might as well make it the best.

If you're going to radiate them at all, radiate them right.

 

[EMhawkeye]

When we had the contrast shortage we were shown some papers that said the sensitivity for acute appy overall on a non con study was over 90%.
Ive seen some dinosaurs wanting oral contrast too for rule out appys. One of my radiology buddies I still quote “only really bad radiologists need oral contrast to look for an appy”.
Yes I realize we are talking about iv.

Some of the dinosaurs refuse to let is give iv contrast on people with shellfish allergies and no documented hx of iv dye reactions. Guess they haven’t read a ACR position paper in 30 years.

 

[BoardingDoc]

When we had the contrast shortage we were shown some papers that said the sensitivity for acute appy overall on a non con study was over 90%.
Ive seen some dinosaurs wanting oral contrast too for rule out appys. One of my radiology buddies I still quote “only really bad radiologists need oral contrast to look for an appy”.
Yes I realize we are talking about iv.

Some of the dinosaurs refuse to let is give iv contrast on people with shellfish allergies and no documented hx of iv dye reactions. Guess they haven’t read a ACR position paper in 30 years.

There's a hospital I used to rotate at as a resident that wouldn't allow IV contrast to anyone that had two different categories of allergies. E.g. bee stings and doxycycline. Eggs and penicillin etc etc. Absolutely bats*** insane.

 

[EMhawkeye]

There's a hospital I used to rotate at as a resident that wouldn't allow IV contrast to anyone that had two different categories of allergies. E.g. bee stings and doxycycline. Eggs and penicillin etc etc. Absolutely bats*** insane.

Ie I’m allergic to benadryl because it makes me sleepy

 

[JacobMcCandles]

For real.
It takes what, 2 more minutes to push the contrast?
KTHXBYE.

It takes 2 minutes to give the contrast, it takes a conversation with the nurse first because they have an allergy to ‘iodine’, then it takes a conversation with the rad tech. If you give up here then you’re doing your pre-treatment protocol. If you don’t give up then you’re talking to the radiologist. Once you think you get to victory you then have another conversation with the rad tech because their GFR is “too low for contrast”, etc., etc. After all this the radiologist then puts in their report that the study is limited from lack of IV contrast.

 

[DocEspana]

It takes 2 minutes to give the contrast, it takes a conversation with the nurse first because they have an allergy to ‘iodine’, then it takes a conversation with the rad tech. If you give up here then you’re doing your pre-treatment protocol. If you don’t give up then you’re talking to the radiologist. Once you think you get to victory you then have another conversation with the rad tech because their GFR is “too low for contrast”, etc., etc. After all this the radiologist then puts in their report that the study is limited from lack of IV contrast.

I have, and this is not a joke, a stack of the most recent ACR recommendations that openly admit contrast nephropathy is a fairy tale. I have a stack of them copied in the cabinet above my computer and just hand them to any rad tech that starts looking at me with that "I got a message for you" look.

 

[JacobMcCandles]

I have, and this is not a joke, a stack of the most recent ACR recommendations that openly admit contrast nephropathy is a fairy tale. I have a stack of them copied in the cabinet above my computer and just hand them to any rad tech that starts looking at me with that "I got a message for you" look.

Also with imaging that is ok to do without a pregnancy test.

 

[RustedFox]

It takes 2 minutes to give the contrast, it takes a conversation with the nurse first because they have an allergy to ‘iodine’, then it takes a conversation with the rad tech. If you give up here then you’re doing your pre-treatment protocol. If you don’t give up then you’re talking to the radiologist. Once you think you get to victory you then have another conversation with the rad tech because their GFR is “too low for contrast”, etc., etc. After all this the radiologist then puts in their report that the study is limited from lack of IV contrast.

- and then if you give the contrast, the patient develops SJS/TEN from an unrelated med, the husband recants the allergy to "red dye", and you get a lawsuit and a board investigation.

Oh, wait. That was me.

 

[BoardingDoc]

Ie I’m allergic to benadryl because it makes me sleepy

Yeah. The multi "allergy" patients could never get contrast. In fairness, if you've got more than 5 allergies listed, your pain is probably from end stage metastatic fibromyalgia, so a scan isn't really going to help anyway.

As an aside, does anyone else enjoy disproving allergies in the ER? Aside from the borderline patients who claim they can't get haldol (I will literally forego seeing anyone else in the dept in order to deep dive through their medical records to prove that they got haldol in the past and didn't die), I really enjoy disproving penicillin allergies.

If you've got a nasty dog bite or something else that needs Unasyn and you have a PCN allergy listed, I generally ask if it's "a childhood thing, or did you get penicillin as an adult and suddenly have a hard time breathing?" If the former (95% of the time) I explain that they probably aren't actually allergic, that I'm going to give them something related to penicillin here, and on the off chance that I'm wrong, we can give you meds to fix it.

At this point, I've probably gotten penicillin off the allergy list of around 100 patients. I'm happy about that.

 

[GonnaBeADoc2222]

Yeah. The multi "allergy" patients could never get contrast. In fairness, if you've got more than 5 allergies listed, your pain is probably from end stage metastatic fibromyalgia, so a scan isn't really going to help anyway.

As an aside, does anyone else enjoy disproving allergies in the ER? Aside from the borderline patients who claim they can't get haldol (I will literally forego seeing anyone else in the dept in order to deep dive through their medical records to prove that they got haldol in the past and didn't die), I really enjoy disproving penicillin allergies.

If you've got a nasty dog bite or something else that needs Unasyn and you have a PCN allergy listed, I generally ask if it's "a childhood thing, or did you get penicillin as an adult and suddenly have a hard time breathing?" If the former (95% of the time) I explain that they probably aren't actually allergic, that I'm going to give them something related to penicillin here, and on the off chance that I'm wrong, we can give you meds to fix it.

At this point, I've probably gotten penicillin off the allergy list of around 100 patients. I'm happy about that.

In 10 years in the ED, I have never seen an iatrogenic allergic reaction to abx, contrast or otherwise

 

[PianoMedic]

In 10 years in the ED, I have never seen an iatrogenic allergic reaction to abx, contrast or otherwise

Just had a guy get anaphylaxis to cefepime the other day. Had to intubate someone after IV contrast dye reaction a few months back.

That said, I also am on board with the unasyn if not an actual anaphylactic reaction in the past. We now have a protocol our pharmacists recommend so I’ve been using it. Gotten a few pcn allergies off the list but that’s been only the past few months.

 

[JacobMcCandles]

If someone says that their mom/dad told them they were allergic then it’s a good bet it can come off the allergy list.

 

[Brigade4Radiant]

Also those studies they had oral and IV contrast and the radiologist wasn't allowed to contact with the ED physician.

I do order some non contrast because I have a very packed waiting room

 

[DocEspana]

Yeah. The multi "allergy" patients could never get contrast. In fairness, if you've got more than 5 allergies listed, your pain is probably from end stage metastatic fibromyalgia, so a scan isn't really going to help anyway.

As an aside, does anyone else enjoy disproving allergies in the ER? Aside from the borderline patients who claim they can't get haldol (I will literally forego seeing anyone else in the dept in order to deep dive through their medical records to prove that they got haldol in the past and didn't die), I really enjoy disproving penicillin allergies.

If you've got a nasty dog bite or something else that needs Unasyn and you have a PCN allergy listed, I generally ask if it's "a childhood thing, or did you get penicillin as an adult and suddenly have a hard time breathing?" If the former (95% of the time) I explain that they probably aren't actually allergic, that I'm going to give them something related to penicillin here, and on the off chance that I'm wrong, we can give you meds to fix it.

At this point, I've probably gotten penicillin off the allergy list of around 100 patients. I'm happy about that.

No it's a personal favorite of mine. They joke around that they're going to name the psychiatric seclusion unit after me because I will so frequently drop whatever I'm doing to pour through a psychiatric patient's chart and prove that some of their more ridiculous allergies are unfounded and then try to use them to further cement the lack of legitimate allergy presence. Obviously, I need some sort of decent evidence there before I do that, but I usually go looking for that evidence.

One of my favorite, non-psychiatric, allergies is when someone gets skin irritation from iodine that didn't get washed off and suddenly the entire computer system is telling us that they can't receive CT scans. Which is the computer making multiple incorrect assumptions in a row.

 

[Janders]

In 10 years in the ED, I have never seen an iatrogenic allergic reaction to abx, contrast or otherwise

Back in first wave of covid when we were intubating patients back-to-back in PAPRs....

I had a patient w/ severe COPD, with exacerbation. Actually didn't SEEM to be COVID (no fever, xray mostly just hyper-inflated). We were NOT allowed to use NEBS! We were NOT allowed to use BIPAP.

So we did tons of albuterol puffs and IV steroids and IV Mag. Called ICU to see if we could put her in one of the step-down ad-hoc respiratory floor things we had converted the PACU into.

Eventually intensivist comes down, walks over to me, is like "janders sorry but she looks REALLY sleepy now, I think you need to tube her"

Yep. Super hypercapnic. We actually only have two available PAPRs b/c all the others are being used to actively intubate patients.

Have the RN give her ceftri / azithro, cover the CAP.

Then just the RT and I go in the room w/ PAPRs to intubate. I push ketamine / Roc myself, then go to the head of the bed. I go to glidescope her, and... her epiglottis is MASSIVE. Like i can't get around it / see around it. I have minimal tools in the room b/c first wave COVID. I end up using the glidescope AND a yankeur like a Miller blade, lifting the epiglottis and sorta DL'ing w/ a crap view and intubating. One of the top 5 worst tubes I've done.

5 minutes later the RN is like "hey her BP is 60". It was 170. She got NO sedation aside from ketamine. Weird.

OH **** THIS IS ANAPHYLAXIS ****. Epipen. Epipen. CVL. Epidrip. BP up to 90, she breaks out in hives everywhere.

While trying to transfer her to 26 different hospitals, I discover one of them knew her, and she had a prior CARDIAC ARREST in the setting of ceftriaxone administration in their hospital. Of course not on our medical record.

She did fine

[I have only seen one case of hives from IV contrast in the past 10 years]

 

[Apollyon]

I have, and this is not a joke, a stack of the most recent ACR recommendations that openly admit contrast nephropathy is a fairy tale. I have a stack of them copied in the cabinet above my computer and just hand them to any rad tech that starts looking at me with that "I got a message for you" look.

When people say this, I have to question: when I was a resident, there were these folks with a Cr of 3.5, and Duke Cards told them, "this is our. After your cath, it's HD", and, the contrast load did, indeed, ace the beans. So, where is the line?

 

[DocEspana]

When people say this, I have to question: when I was a resident, there were these folks with a Cr of 3.5, and Duke Cards told them, "this is our. After your cath, it's HD", and, the contrast load did, indeed, ace the beans. So, where is the line?

There is no line. The ACR (and every other organization) say that this falls into two categories

1) transient dips in creatinine that have never been shown to be permanent or lead to electrolyte dysfunction, even in the critically renal impaired*

2) anecdotes that are not reproducible in any retrospective analysis, but may represent some subtle phenomenon that part 1 above is not picking up.

It's for this reason that the recommendation is to never withhold contrast regardless of the renal function if it is a standard part of the evaluation for a given pathology. The only recommendation is to either arrange dialysis if the patient is on HD but makes urine, or to fluid bolus after the CT anyone with dicey GFR. This is how they resolve the fact that anecdotes of 2) exist despite all the data saying only 1) is "true".

* Anecdotally, the nephrologist down at my center are totally on board with this idea that contrast only causes a transient dip in GFR that is not actually related to true renal function, but is more of a surrogate marker thing. I thoroughly enjoy reading the passive aggressive consult notes they write for anyone who is renal impaired that I give CT contrast to and then admit. Because the hospital is service is not yet up to date on this, consults nephro, and nephro gets grumpy. I don't even think they realize that the nephrologists are being sassy with them in the note.

 

[Apollyon]

There is no line. The ACR (and every other organization) say that this falls into two categories

1) transient dips in creatinine that have never been shown to be permanent or lead to electrolyte dysfunction, even in the critically renal impaired

2) anecdotes that are not reproducible in any retrospective analysis, but may represent some subtle phenomenon that part 1 above is not picking up.

It's for this reason that the recommendation is to never withhold contrast regardless of the renal function if it is a standard part of the evaluation for a given pathology. The only recommendation is to either arrange dialysis if the patient is on HD but makes urine, or to fluid bolus after the CT anyone with dicey GFR. This is how they resolve the fact that anecdotes of 2) exist despite all the data saying only 1) is "true".

You state there are many studies, but, I don't know them. What a quick paper search reveals is that it is CT related to which they refer. It seems like there is a definite line between amounts used for CTs, and amounts used for cardiac cath. Casually, it appears to me that you can can't pro rata apply the CT studies to the cath patients.

It is, vaguely, kinda insulting to call it a "fairy tale". It doesn't happen with CT, but it certainly does with cards, and the direct relation is volume of contrast, and the type.

 

[thegenius]

I have, and this is not a joke, a stack of the most recent ACR recommendations that openly admit contrast nephropathy is a fairy tale. I have a stack of them copied in the cabinet above my computer and just hand them to any rad tech that starts looking at me with that "I got a message for you" look.

This whole CIN thing will never change until ACR says it's no problem never getting a Cr prior to a contrast enhanced CT. Like it's actively promoted. Old habits die hard

 

[TooMuchResearch]

This whole CIN thing will never change until ACR says it's no problem never getting a Cr prior to a contrast enhanced CT. Like it's actively promoted. Old habits die hard

If I can do it in stroke codes and trauma activations and times when I really really want to go without creatinine, do I really ever need it?

 

[DocEspana]

You state there are many studies, but, I don't know them. What a quick paper search reveals is that it is CT related to which they refer. It seems like there is a definite line between amounts used for CTs, and amounts used for cardiac cath. Casually, it appears to me that you can can't pro rata apply the CT studies to the cath patients.

It is, vaguely, kinda insulting to call it a "fairy tale". It doesn't happen with CT, but it certainly does with cards, and the direct relation is volume of contrast, and the type.

2015 ACR "current thinking" which didn't change recommendations but was saying in no unclear terms that they have tried to show any evidence of contrast induced nephropathy existing and simply cannot prove that it is a phenomenon in the setting of a contrast enhanced CT.

https://www.ajronline.org/doi/10.2214/AJR.14.14259

2017 annals weighing in, in no uncertain terms, that it is not a thing. "Intravenous contrast media (typically iohexol or iodixanol) used in computed tomography (CT) does not appear to be associated with chronic kidney disease, dialysis, kidney transplant or acute kidney injury, despite long-held fears to the contrary."

https://www.annemergmed.com/article/S0196-0644(16)31388-9/fulltext

2020, and current, ACR recommendations which state that the risks are "difficult to assess" (in their abstract) but then has data and analysis which state that it's been shown only in anecdote and in poorly designed study and never in any well designed study. Regardless, the recommendation is to never withhold contrast based on the renal function, only to adjust what you do in the aftermath of the contrast bolus based on the renal function.

https://pubs.rsna.org/doi/full/10.1148/radiol.2019192094

I'd post more studies, but let's be honest, if thats the current stance from annals (can't find anything newer) and the consensus statement from ACR any research from the two fields that I think is relevant is going to be one of the references in those two articles

I'm going out on a limb and I could be 100% wrong, but aren't the contrast mediums in CT studies and in coronary angiography completely different? If I'm not incorrect, and they are different, that probably has a lot more to do with it. Also the volumes are different as well (that part I know).

This whole CIN thing will never change until ACR says it's no problem never getting a Cr prior to a contrast enhanced CT. Like it's actively promoted. Old habits die hard

The 2020 ACR recommendations are basically that the only reason to get a creatinine is to decide who needs optional fluid bolus after the CT. That's about 90% of the way to saying that creatinine doesn't need to be drawn at all.

 

[Apollyon]

2015 ACR "current thinking" which didn't change recommendations but was saying in no unclear terms that they have tried to show any evidence of contrast induced nephropathy existing and simply cannot prove that it is a phenomenon in the setting of a contrast enhanced CT.

https://www.ajronline.org/doi/10.2214/AJR.14.14259

2017 annals weighing in, in no uncertain terms, that it is not a thing. "Intravenous contrast media (typically iohexol or iodixanol) used in computed tomography (CT) does not appear to be associated with chronic kidney disease, dialysis, kidney transplant or acute kidney injury, despite long-held fears to the contrary."

https://www.annemergmed.com/article/S0196-0644(16)31388-9/fulltext

2020, and current, ACR recommendations which state that the risks are "difficult to assess" (in their abstract) but then has data and analysis which state that it's been shown only in anecdote and in poorly designed study and never in any well designed study. Regardless, the recommendation is to never withhold contrast based on the renal function, only to adjust what you do in the aftermath of the contrast bolus based on the renal function.

https://pubs.rsna.org/doi/full/10.1148/radiol.2019192094

I'd post more studies, but let's be honest, if thats the current stance from annals (can't find anything newer) and the consensus statement from ACR any research from the two fields that I think is relevant is going to be one of the references in those two articles

I'm going out on a limb and I could be 100% wrong, but aren't the contrast mediums in CT studies and in coronary angiography completely different? If I'm not incorrect, and they are different, that probably has a lot more to do with it. Also the volumes are different as well (that part I know).



The 2020 ACR recommendations are basically that the only reason to get a creatinine is to decide who needs optional fluid bolus after the CT. That's about 90% of the way to saying that creatinine doesn't need to be drawn at all.

You didn't need to post all of that. I said, "CT, yes, cardiac cath, no". I didn't doubt it, once I looked. Maybe I didn't make that clear.

Exact same contrast. It's for the C arm. Just a lot more of it (especially if there is a ventriculogram).

 

[thegenius]

If I can do it in stroke codes and trauma activations and times when I really really want to go without creatinine, do I really ever need it?

well yea because we will get sued and lose based on the fact that the guidelines do not unequivocably support your position, that and the prosecution will find numerous radiologists saying that CIN "kinda exists like a little bit."
I'm just answering as a douche BTW