1.1. Acute adverse reactions

Definition: An adverse reaction which occurs within 1 hour of contrast medium injection.

Classification

Mild
Nausea, mild vomiting
Urticaria
Itching
Moderate
Severe vomiting
Marked urticaria
Bronchospasm
Facial/laryngeal edema
Vasovagal attack
Severe
Hypotensive shock
Respiratory arrest
Cardiac arrest
Convulsion

1.1.1 Acute adverse reactions to iodine-based contrast media

Risk factors for acute reactions

PATIENT-RELATED
Patient with a history of:
  • Previous moderate or severe acute reaction (see classification above) to an iodine-based contrast agent.
  • Asthma.
  • Allergy requiring medical treatment.
CONTRAST-MEDIUM-RELATED
  • High osmolality ionic contrast media.

To reduce the risk of an acute reaction

For all patients
  • Use a non-ionic contrast medium.
  • Keep the patient in the Radiology Department for 30 min after contrast medium injection.
  • Have the drugs and equipment for resuscitation readily available (see 1.1.3).
For patients at increased risk of reaction (see risk factors above)
  • Consider an alternative test not requiring an iodine-based contrast agent.
  • Use a different iodine-based agent for previous reactors to contrast medium.
  • Consider the use of premedication. Clinical evidence of the effectiveness of premedication is limited. If used, a suitable premedication regime is prednisolone 30 mg (or methylprednisolone 32 mg) orally given 12 and 2 hours before contrast medium.
Extravascular administration of iodine-based contrast media
When absorption or leakage into the circulation is possible, take the same precautions as for intravascular administration.

1.1.2 Acute adverse reactions to gadolinium-based contrast media

Note: The risk of an acute reaction to a gadolinium-based contrast agent is lower than the risk with an iodine-based contrast agent, but severe reactions to gadolinium-based contrast media may occur.

Risk factors for acute reactions

PATIENT-RELATED
Patient with a history of:
  • Previous acute reaction to gadolinium-based contrast agent.
  • Asthma.
  • Allergy requiring medical treatment.
CONTRAST-MEDIUM-RELATED
The risk of reaction is not related to the osmolality of the contrast agent: the low doses used make the osmolar load very small.

To reduce the risk of an acute reaction

For all patients
  • Keep the patient in the Radiology Department for 30 min after contrast medium injection.
  • Have the drugs and equipment for resuscitation readily available (see 1.1.3).
For patients at increased risk of reaction (see risk factors above)
  • Consider an alternative test not requiring a gadolinium-based contrast agent.
  • Use a different gadolinium-based agent for previous reactors to contrast medium.
  • Consider the use of premedication. There is no clinical evidence of the effectiveness of premedication. If used, a suitable premedication regime is prednisolone 30 mg (or methylprednisolone 32 mg) orally given 12 and 2 hours before contrast medium.

1.1.3 Management

First line emergency drugs and instruments which should be in the examination room.

Oxygen
Adrenaline 1:1,000
Atropine
β2-agonist metered dose inhaler
I.V. Fluids – normal saline or Ringer’s solution
Anti-convulsive drugs (diazepam)
Sphygmomanometer
One-way mouth “breather” apparatus

Simple guidelines for first line treatment of acute reactions to all contrast media

The same reactions are seen after iodine- and gadolinium-based contrast agents and after ultrasound contrast agents. The incidence is highest after iodine-based contrast agents and lowest after ultrasound agents.

Nausea/Vomiting
Transient: Supportive treatment
Severe, protracted: Appropriate antiemetic drugs should be considered.

Urticaria
Scattered, transient: Supportive treatment including observation.
Scattered, protracted: Appropriate H1-antihistamine intramuscularly or intravenously should be considered. Drowsiness and/or hypotension may occur.
Generalized: Appropriate H1-antihistamine intramuscularly or intravenously should be given. Drowsiness and/or hypotension may occur. Consider Adrenaline 1:1,000, 0.1-0.3 ml (0.1-0.3 mg) intramuscularly in adults, 50% of adult dose to pediatric patients between 6 and 12 years old and 25% of adult dose to pediatric patients below 6 years old. Repeat as needed.

Bronchospasm

  1. Oxygen by mask (6-10 l/min)
  2. β-2-agonistmetereddoseinhaler(2-3deepinhalations)
  3. Adrenaline

Normal blood pressure
Intramuscular: 1:1,000, 0.1-0.3 ml (0.1-0.3 mg) [use smaller dose in a patient with coronary artery disease or elderly patient]
In pediatric patients: 50% of adult dose to pediatric patients between 6 and 12 years old and 25% of adult dose to pediatric patients below 6 years old. Repeat as needed.

Decreased blood pressure
Intramuscular: 1:1,000, 0.5 ml (0.5 mg),
In pediatric patients: 6-12 years: 0.3 ml (0.3 mg) intramuscularly
< 6 years: 0.15 ml (0.15 mg) intramuscularly

Laryngeal edema

  1. Oxygen by mask (6 – 10 l/min)
  2. Intramuscular adrenaline (1:1,000), 0.5 ml (0.5 mg) for adults, repeat as needed.

In pediatric patients: 6-12 years: 0.3 ml (0.3 mg) intramuscularly
< 6 years: 0.15 ml (0.15 mg) intra

Hypotension
Isolated hypotension

  1. Elevate patient’s legs
  2. Oxygen by mask (6-10 l/min)
  3. Intravenous fluid: rapidly, normal saline or Ringer’s solution
  4. If unresponsive: adrenaline: 1:1,000, 0.5 ml (0.5 mg) intramuscularly, repeat as needed
    In pediatric patients: 6-12 years: 0.3 ml (0.3 mg) intramuscularly
    < 6 years: 0.15 ml (0.15 mg) intramuscularly

Vagal reaction (hypotension and bradycardia)
  1. Elevate patient’s legs
  2. Oxygen by mask (6-10 l/min)
  3. Atropine 0.6-1.0 mg intravenously, repeat if necessary after 3-5 min, to 3 mg total (0.04 mg/kg) in adults. In pediatric patients give 0.02 mg/kg intravenously (max. 0.6 mg per dose), repeat if necessary to 2 mg total.
  4. Intravenous fluids: rapidly, normal saline or Ringer’s solution

Generalized anaphylactoid reaction

  1. Call for resuscitation team
  2. Suction airway as needed
  3. Elevate patient’s legs if hypotensive
  4. Oxygen by mask (6 – 10 l/min)
  5. Intramuscular adrenaline (1:1,000), 0.5 ml (0.5 mg) in adults.
    Repeat as needed.
    In pediatric patients: 6-12 years: 0.3 ml (0.3 mg)
    intramuscularly
    < 6 years: 0.15 ml (0.15 mg) intramuscularly
  6. Intravenous fluids (e.g. normal saline, Ringer’s solution).
  7. H1-blocker e.g. diphenhydramine 25-50 mg intravenously

1.2 Late adverse reactions

Definition
A late adverse reaction to intravascular iodine-based contrast medium is defined as a reaction which occurs 1 h to 1 week after contrast medium injection.
Reactions:
Skin reactions similar in type to other drug induced eruptions. Maculopapular rashes, erythema, swelling and pruritus are most common. Most skin reactions are mild to moderate and self-limiting.

A variety of late symptoms (e.g., nausea, vomiting, headache, musculoskeletal pains, fever) have been described following contrast medium, but many are not related to contrast medium.
Risk factors for skin reactions:
  • Previous late contrast medium reaction.
  • Interleukin-2 treatment.
  • Use of nonionic dimers.
Management:
Symptomatic and similar to the management of other drug-induced skin reactions e.g. antihistamines, topical steroids and emollients.
Recommendations:
Patients who have had a previous contrast medium reaction, or who are on interleukin-2 treatment should be advised that a late skin reaction is possible and that they should contact a doctor if they have a problem.

Patch and delayed reading intradermal tests may be useful to confirm a late skin reaction to contrast medium and to study cross- reactivity patterns with other agents.

To reduce the risk of repeat reaction, use another contrast agent than the agent precipitating the first reaction. Avoid agents which have shown cross-reactivity on skin testing.

Drug prophylaxis is generally not recommended.

Note: Late skin reactions of the type which occur after iodine-based contrast media have not been described after gadolinium-based and ultrasound contrast media.

1.3 Very late adverse reactions

Definition: An adverse reaction which usually occurs more than 1 week after contrast medium injection.

Type of reaction

Iodine-based contrast media
Thyrotoxicosis
Gadolinium-based contrast media
Nephrogenic systemic fibrosis

1.3.1 Thyrotoxicosis

At risk
  • Patients with untreated Graves’ disease
  • Patients with multinodular goiter and thyroid autonomy, especially if they are elderly and/or live in area of dietary iodine deficiency
Not at risk
Patients with normal thyroid function
Recommendations
  • Iodinated contrast media should not be given to patients with manifest hyperthyroidism.
  • Prophylaxis is generally not necessary.
  • In selected high-risk patients, prophylactic treatment may be given by an endocrinologist; this is more relevant in areas of dietary iodine deficiency.
  • Patients at risk should be closely monitored by endocrinologists after iodine- based contrast medium injection.
  • Intravenous cholangiographic contrast media should not be given to patients at risk.

1.3.2 Nephrogenic systemic fibrosis

A diagnosis of nephrogenic systemic fibrosis (NSF) should only be made if the Yale NSF Registry clinical and histopathological criteria are met (J Am Acad Dermatol 2011; 65:1095-1106). The link between nephrogenic systemic fibrosis (NSF) and gadolinium-based contrast agents was recognized in 2006.

Clinical features of NSF
Onset: From the day of exposure for up to 2-3 months, sometimes up to years after exposure.

Initially
  • Pain
  • Pruritus
  • Swelling
  • Erythema
  • Usually starts in the legs

Later
  • Thickened skin and subcutaneous tissues – ‘woody’ texture and brawny plaques
  • Fibrosis of internal organs, e.g. muscle, diaphragm, heart, liver, lungs

Result
  • Contractures
  • Cachexia
  • Death, in a proportion of patients

Patients

At higher risk
  • Patients with CKD 4 and 5 (GFR < 30ml/ min)
  • Patients on dialysis
  • Patients with acute kidney insufficiency
At lower risk
Patients with CKD 3 (GFR 30-59ml/min)
Not at risk of NSF
Patients with stable GFR > 60 ml/min

Contrast agents:

Risk classification (based on laboratory data) and Recommendations

Highest risk of NSF

Contrast agents
Gadodiamide (Omniscan®)
  • Ligand: Non-ionic linear chelate(DTPA-BMA)
  • Incidence of NSF: 3-18% in at-risk subjects

Gadopentetate dimeglumine (Magnevist® plus generic products)
  • Ligand: Ionic linear chelate (DTPA)
  • Incidence of NSF: Estimated to be 0.1 to 1 % in at risk subjects

Gadoversetamide (Optimark®)
  • Ligand: Non-ionic linear chelate(DTPA-BMEA)
  • Incidence of NSF: Unknown.
Recommendations
These agents are CONTRAINDICATED in
  • patients with CKD 4 and 5 (GFR < 30 ml/min), including those on dialysis
  • acute renal insufficiency
  • pregnant women
  • neonates

These agents should be used with CAUTION in
  • patients with CKD 3 (GFR 30-60 ml/min)
    There should be at least 7 days between two injections
  • children less than 1 year old

Lactating women: Stop breastfeeding for 24 hours and discard the milk.

Serum creatinine (eGFR) measurement and clinical assessment of patient before administration: Mandatory

These agents should never be given in higher doses than 0.1 mmol/kg per examination in any patient

Intermediate risk of NSF

Contrast agents
Gadobenate dimeglumine (Multihance®)
  • Ligand: Ionic linear chelate (BOPTA)
  • Incidence of NSF: No uncon- founded* cases have been reported.
  • Special feature: It is a combined extracellular and liver specific agent with 2-3% albumin binding. Diagnostic results can be achieved with 50% lower doses than with usual extracellular agents. In man ~4% is excreted via the liver.

Gadofosveset trisodium (Vasovist®, Ablavar®)
  • Ligand: Ionic linear chelate (DTPA-DPCP)
  • Incidence of NSF: No unconfounded* cases reported, but experience is limited
  • Special feature: It is a blood pool agent with affinity to albumin (>90%). Diagnostic results can be achieved with 50% lower doses than extracellular Gd-CM. Biological hal--life is 12 times longer than for extracellular agents (18 hours compared to 11⁄2 hours, respectively); 5% is excreted via the bile.

Gadoxetate disodium (Primovist®, Eovist®) Ligand: Ionic linear chelate (EOB-DTPA)
  • Incidence of NSF: No unconfounded* cases have been reported but experience is limited.
  • Special feature: It is an organ specific gadolinium contrast agent with 10% protein binding and 50% excretion by hepatocytes. Diagnostic results can be achieved with lower doses than extracellular Gd-CM.
Recommendations
These agents should be used with CAUTION in
  • patients with CKD 4 and 5 (GFR < 30 ml/min)
    There should be at least 7 days between two injections

Pregnant women:
Can be used to give essential diagnostic information.

Lactating women: The patient should discuss with the doctor whether the breast milk should be discarded in the 24 hours after contrast medium.

Laboratory testing of renal function (eGFR) is not mandatory. Renal function assessment by questionnaire should be used if serum creatinine is not measured.

Lowest risk of NSF

Contrast agents
Gadobutrol (Gadovist®, Gadavist®)
  • Ligand: Non-ionic cyclic chelate (BT-DO3A)
  • Incidence of NSF: A few unconfounded* cases have been reported, but there is uncertainty about the histopathologic changes.

Gadoterate meglumine (Dotarem®, Magnescope®)
  • Ligand: Ionic cyclic chelate (DOTA)
  • Incidence of NSF: No unconfounded*
    cases have been reported.

Gadoteridol (Prohance®)
  • Ligand: Non-ionic cyclic chelate (HP-DO3A)
  • Incidence of NSF: No unconfounded* cases have been reported.
Recommendations
These agents should be used with CAUTION in
  • patients with CKD 4 and 5 (GFR < 30 ml/min)
    There should be at least 7 days between two injections

Pregnant women:
Can be used to give essential diagnostic information.

Lactating women: The patient should discuss with the doctor whether the breast milk should be discarded in the 24 hours after contrast medium.

Laboratory testing of renal function (eGFR) is not mandatory. Renal function assessment by questionnaire should be used if serum creatinine is not measured.
Patients with NSF
Gadolinium-based contrast media should only be used if the indication is vital and then only intermediate or low risk agents should be used.
Recommendation for all patients
Never deny a patient a clinically well- indicated enhanced MRI examination. In all patients use the smallest amount of contrast medium necessary for a diagnostic result.
Always record the name and dose of the contrast agent used in the patient records.

*Confounded cases: If two different Gd-CM have been injected, it is impossible to determine with certainty which agent triggered the development of NSF and the situation is described as ‘confounded’.

Unconfounded cases: The patient has never been exposed to more than one agent.

Definition: Contrast induced nephropathy (CIN) is a condition in which a decrease in renal function occurs within 3 days of the intravascular administration of a CM in the absence of an alternative aetiology. An increase in serum creatinine by more than 25% or 44 μmol/l (0.5 mg/dl) indicates CIN.

2.1 Renal adverse reactions to iodine-based contrast media

Risk Factors for Contrast Medium-Induced Nephropathy

PATIENT-RELATED
  • eGFR less than 60 ml/min/1.73 m2 before intra-arterial administration
  • eGFR less than 45 ml/min/1.73 m2 before intravenous administration
  • In particular in combination with
    • Diabetic nephropathy
    • Dehydration
    • Congestive heart failure (NYHA grade 3-4) and low LVEF
    • Recent myocardial infarction (< 24 h)
    • Intra-aortic balloon pump
    • Peri-procedural hypotension
    • Low haematocrit level
    • Age over 70
    • Concurrent administration of nephrotoxic drugs
  • Known or suspected acute renal failure
Procedure-related
  • Intra-arterial administration of contrast medium
  • High osmolality agents
  • Large doses of contrast medium
  • Multiple contrast medium administrations within a few days

2.1.1 Time of referral

Elective Examination

Identify patients who require measurement of renal function

    Determine eGFR (or SCr) within 7 days of contrast medium administration
  • Patients with known eGFR less than 60 ml/min/1.73 m2
  • Patients who will receive intra- arterial contrast medium
  • Age over 70
  • Patients with a history of:
    • Renal disease
    • Renal surgery
    • Proteinuria
    • Diabetes mellitus
    • Hypertension
    • Gout
    • Recent nephrotoxic drugs

Emergency Examination

Identify at-risk patients (see above) if possible:
  • Determine eGFR if the procedure can be deferred until the result is available without harm to the patient.
  • If eGFR cannot be obtained, follow the protocols for patients with eGFR less than 60 ml/min/1.73 m2 for intra-arterial administration and eGFR less than 45 ml/min/1.73 m2 for intravenous administration as closely as clinical circumstances permit.

2.1.2 Before the examination

Elective Examination

At risk patients (see above)
  • Consider an alternative imaging method not using iodine-based contrast media.
  • Discuss the need to stop nephrotoxic drugs with the referring physician.
  • Start volume expansion. A suitable protocol is intravenous normal saline, 1.0-1.5 ml/kg/h, for at least 6 h before and after contrast medium. An alternative protocol is intravenous sodium bicarbonate (154 mEq/l in dextrose 5% water), 3 ml/kg/h for 1 h before contrast medium and 1 ml/kg/h for 6 h after contrast medium.

Emergency Examination

At risk patients (see above)
  • Consider an alternative imaging method not using iodine-based contrast media.
  • Start volume expansion as early as possible before contrast medium administration (see elective examination).

2.1.3 Time of examination

At risk patients (see above)
  • Use low or iso-osmolar contrast media.
  • Use the lowest dose of contrast medium consistent with a diagnostic result.
Patients not at increased risk
  • Use the lowest dose of contrast medium consistent with a diagnostic result.

2.1.4 After the examination

At risk patients
  • Continue volume expansion
  • Determine eGFR 48-72 h after contrast medium

Note: No pharmacological prophylaxis (with renal vasodilators, receptor antagonists of endogenous vasoactive mediators or cytoprotective drugs) has yet been shown to offer consistent protection against contrast induced nephropathy.

2.2 Renal adverse reactions to gadolinium-based contrast media.

Mr Examinations

  • The risk of nephrotoxicity is very low when gadolinium-based contrast media are used in approved doses.
  • In patients with reduced renal function refer to ESUR guidelines on NSF, 1.3.2

RADIOGRAPHIC EXAMINATIONS

  • Gadolinium-based contrast media should not be used for radiographic examinations in patients with renal impairment.
  • Gadolinium-based contrast media are more nephrotoxic than iodine-based contrast media in equivalent X-ray attenuating doses.

2.3 Patients taking Metformin

2.3.1 Iodine-based contrast media

  1. Patients with eGFR equal to or greater than 60 ml/min/1.73m2 (CKD 1 and 2) can continue to take metformin normally.
  2. Patients with eGFR 30-59 ml/min/1.73 m2 (CKD 3)
    1. Patients receiving intravenous contrast medium with eGFR equal to or greater than 45 ml/min/1.73 m2 can continue to take metformin normally.
    2. Patients receiving intra-arterial contrast medium, and those receiving intravenous contrast medium with an eGFR between 30 and 44 ml/min/1.73 m2, should stop metformin 48 h before contrast medium and should only restart metformin 48 h after contrast medium if renal function has not deteriorated.
  3. Patients with eGFR less than 30 ml/min/1.73 m2 (CKD 4 and 5), or with an intercurrent illness causing reduced liver function or hypoxia. Metformin is contraindicated and iodine-based contrast media should be avoided.
  4. Emergency patients. Metformin should be stopped from the time of contrast medium administration. After the procedure, the patient should be monitored for signs of lactic acidosis. Metformin should be restarted 48 h after contrast medium if serum creatinine/eGFR is unchanged from the pre-imaging level.

2.3.2 Gadolinium-based contrast media.

No special precautions are necessary when diabetic patients on metformin are given gadolinium-based contrast medium.

2.4 Dialysis and contrast medium administration

All iodine and gadolinium-based contrast media can be removed by hemodialysis or peritoneal dialysis. However, there is no evidence that hemodialysis protects patients with impaired renal function from contrast medium induced nephropathy or nephrogenic systemic fibrosis. In all patients, avoid osmotic and fluid overload. To avoid the risk of NSF refer to 1.3.2

Patients on dialysis

Hemodialysis
Iodine-based contrast medium
  • Correlation of time of the contrast medium injection with the hemodialysis session is unnecessary.
  • Extra hemodialysis session to remove contrast medium is unnecessary.

Gadolinium-based contrast medium
  • Correlation of time of the contrast medium injection with the hemodialysis session is recommended.
  • Extra hemodialysis session to remove contrast medium as soon as possible after it has been administered is recommended.

Continuous ambulatory peritoneal dialysis
Iodine-based contrast medium
  • Hemodialysis to remove the contrast medium is unnecessary for iodine-based contrast medium, but for gadolinium- based contrast medium. It should be discussed with referring physician.

Gadolinium-based contrast medium
  • Hemodialysis to remove the contrast medium is unnecessary for iodine-based contrast medium, but for gadolinium- based contrast medium. It should be discussed with referring physician.

3.1 Contrast medium extravasation.

Type of injuries
  • Most injuries are minor.
  • Severe injuries include skin ulceration, soft tissue necrosis, and compartment syndrome.

Risk factors

Technique-related
  • Use of a power injector.
  • Less optimal injection sites including lower limb and small distal veins.
  • Large volume of contrast medium.
  • High osmolar contrast media.
Patient-related
  • Inability to communicate.
  • Fragile or damaged veins.
  • Arterial insufficiency.
  • Compromised lymphatic and/or venous drainage.
  • Obesity
To reduce the risk
  • Intravenous technique should always be meticulous using appropriate sized plastic cannula placed in a suitable vein to handle the flow rate used during the injection.
  • Test injection with normal saline.
  • Use non-ionic iodine-based contrast medium.
Treatment
  • Conservative management is adequate in most cases
    • limb elevation
    • apply ice packs
    • careful monitoring
  • If a serious injury is suspected, seek the advice of a surgeon.

3.2 Pulmonary effects of iodine-based contrast media

Pulmonary adverse effects
  • Bronchospasm.
  • Increased pulmonary vascular resistance.
  • Pulmonary edema.
Patients at high risk
  • History of asthma.
  • History of pulmonary hypertension.
  • Incipient cardiac failure.
To reduce the risk of pulmonary adverse effects
  • Use low or iso-osmolar contrast media.
  • Avoid large doses of contrast media.

3.3 Effects of iodine-based contrast media on blood and endothelium

The clinically important adverse effect of iodine-based contrast media on blood and endothelium is thrombosis.

It is recognized that:
  • All contrast media have anticoagulant properties, especially ionic agents.
  • High osmolar ionic contrast media may induce thrombosis due to endothelial damage, particularly in phlebographic procedures.
  • Drugs and interventional devices that decrease the risk of thromboembolic complications during interventional procedures minimize the importance of the effects of contrast media.

Guidelines

  • Meticulous angiographic technique is mandatory and is the most important factor in reducing thromboembolic complications.
  • Low- or iso-osmolar contrast media should be used for diagnostic and interventional angiographic procedures including phlebography.

3.4 Contrast media and catecholamine producing tumors (pheochromocytoma and paraganglioma)

Preparation

  1. Before intravenous iodine- or gadolinium-based contrast medium: No special preparation is required.
  2. Before intra-arterial iodine-based contrast medium: α- and β-adrenergic blockade with orally administered drugs under the supervision of the referring physician is recommended.

Type of contrast medium which should be used

Iodine-based: non-ionic agent.
Gadolinium-based: any agent, ionic or non-ionic

3.5 Pregnancy and lactation

Pregnancy
  1. In exceptional circumstances, when radiographic examination is essential, iodine- based contrast media may be given to the pregnant female.
  2. Following administration of iodine-based agents to the mother during pregnancy, thyroid function should be checked in the neonate during the first week.
  1. When there is a very strong indication for enhanced MR, the smallest possible dose of one of the most stable gadolinium contrast agents (see Contrast agents: Intermediate and low risk of NSF, 1.3.2) may be given to the pregnant female.
  2. Following administration of gadolinium-based agents to the mother during pregnancy, no neonatal tests are necessary.
Lactation
Breast feeding may be continued normally when iodine-based agents are given to the mother.
Breast feeding should be avoided for 24 hours after contrast medium if high risk agents are used.
Pregnant or lactating mother with renal impairment
See renal adverse reactions (see 2.1). No additional precautions are necessary for the fetus or neonate.
Do not administer gadolinium-based contrast agents.

3.6 Interaction with other drugs and clinical tests

General recommendation
Be aware of the patients drug history.
Keep a proper record of the contrast medium injection (time, dose, name).
Do not mix contrast media with other drugs in tubes and syringes.

Drugs needing special attention

Metformin
Refer to renal adverse reactions section (2.1).
Nephrotoxic drugs
Cyclosporine
Cisplatin
Aminoglycosides
Non steroid anti- inflammatory drugs
Refer to renal adverse reactions section (2.1).
Beta-blocker
β-blockers may impair the management of bronchospasm and the response to adrenaline.
Interleukin-2
Refer to late adverse reactions section (1.2).

Biochemical assays

Recommendation
Do not perform non-emergency biochemical analysis of blood and urine collected in the 24 hours after contrast medium injection.

Isotope studies and/or treatment

Thyroid
Patients undergoing therapy with radioactive iodine should not have received iodine-based contrast media for at least two months before treatment.
Isotope imaging of the thyroid should be avoided for two months after iodine-based contrast medium injection.
Bone, red blood cell labelling
Avoid iodine-based contrast medium injection for at least 24 hours before the isotope study.

3.7 Safety of ultrasound contrast media

Statement
Ultrasound contrast media are generally safe.
Contraindication
Severe heart disease (e.g. New York class III/IV).
Type and severity of reactions
  • The majority of reactions are minor (e.g. headache, nausea, sensation of heat, altered taste) and self-resolving.
  • More severe acute reactions are rare and are similar to those after iodine and gadolinium-based agents (see 1.1).
To reduce the risk
  • Check for intolerance to any of the components of the contrast agent
  • Use the lowest level of acoustic output and shortest scanning time to allow a diagnostic examination.
Treatment
If a serious event occurs – see non-renal adverse reaction section.

3.8 Safety of barium contrast media Contraindications

Contraindications
Integrity of gut wall compromised
Use iodine-based water-soluble contrast media
In neonates and patients at risk of leakage into mediastinum and/ or lungs use low- or isoosmolar contrast media.

Previous allergic reactions to barium products
Use iodine-based water-soluble contrast media and be prepared to treat a reaction.
Cautions
Bowel strictures
Use only small amounts.

Extensive colitis
Avoid barium enemas.
Complications
Reduced bowel motility
Encourage fluid intake.

Venous intravasation
  • Early identification and careful observation.
  • Antibiotics and intravenous fluids.
  • Emergency treatment may be needed.

Aspiration
  • Bronchoscopic removal for large amounts.
  • Chest physiotherapy.
  • Antibiotics.