Contrast policies

UHS Contrast Policy:

1. Cr/GFR check is required for:
   1. All patients age > 55 years
   2. Patients < 55 years of age with DM, HTN, known kidney disease or single kidney
   3. Repeat contrast dose within 24 hours (i.e. CT done less than 24 hours prior
2. Hydration is required for patients with GFR 31-45 per protocol outlined below. Patients with GFR of 30 or below maybe given iodinated contrast only in exceptional circumstances after discussions between the Radiologist and referring provider
3. Metformin does not need to be stopped for GFR > 30.

Contrast Allergy Protocols (from 2016 ACR Contrast Manual):

Note: IV steroids have not been shown to be effective when administered less than 4 to 6 hours prior to contrast injection.

Elective Premedication:

1. **Preferred** 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.
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.

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.
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 methylprednisolone, aspirin, or NSAIDs, especially if asthmatic. Also diphenhydramine 50 mg IV 1 hour prior to contrast injection.
3. Omit steroids entirely and give diphenhydramine 50 mg IV.

FAQs from Dr. Suri:

1. Metformin – to hold or not to hold after IV contrast?

a. Metformin is not a contraindication for CECT for patients with eGFR > 30

b. patients are NOT REQUIRED TO HOLD METFORMIN before or after IV iodinated contrast

2. If patient is undergoing dialysis for chronic renal failure – dialysis same day after contrast load?

a. Proceed with CECT and dialyze as per patients’ dialysis schedule (dialysis DOES NOT have to be done the same day or within 24 hours)

3. If patient has a CECT (contrast enhanced) exam in the ED and requires a repeat CECT within < 24 hours?

a. If Initial eGFR > 45: proceed with second CECT provided we adequately hydrate. Recommend total contrast volume be less than 250cc in 24 hours for adults (or 2ml/Kg for Pediatrics)

b. If initial eGFR 31-45: avoid contrast dose x 24 hrs

c. No CECT with eGFR ≤ 30

4. Oral or rectal contrast is NOT required for any abdominal ER exams

5. Patients with prior known reactions to iodinated contrast are prepped with:

a. 50 mg Prednisone 13 hours, 7 hours and 1 hour prior to procedure + 50 mg Benadryl 1 hour prior to procedure

6. If eGFR:

a. > 45 – proceed with CECT (contrast enhanced)

b. 31-45 - proceed with CECT (contrast enhanced) and hydrate per UHS protocol - 200 cc/hr x 2 hrs (pre) + 400 cc bolus (post)

c. ≤ 30 – no contrast unless on dialysis