Implementation plan

Recommendation

Time frame for implemen

tation:
<1 year,

1 to 3years or

>3 years

Expected effect on costs

Limitations for implemen

tation

Barriers to implemen

tation1

Actions needed for implemen

tation2

Parties responsible for actions3

Other remarks

Preparation:

  • Have the drugs (as a minimum requirement: adrenaline, salbutamol, H1-antihistamine (clemastine) IV, and corticosteroid IV (e.g. prednisolone)), equipment and protocol for treatment of an acute adverse reaction readily available in every room where contrast agents are administered.
  • Adhere to local protocols for accessibility of a resuscitation and emergency response team.
  • Keep every patient with an acute hypersensitivity reaction to CM in a medical environment for at least 30 minutes after contrast agent injection. Moderate and severe reactions need a prolonged observation.

1 to 3 years

None

Lack of knowledge, lack of availability of drugs for treatment of acute reactions in rooms where CM is administered

Lack of knowledge, lack of availability of drugs for treatment of acute reactions in rooms where CM is administered

Dissemination of guideline, development of local protocols for treatment of acute hypersensitivity reactions after CM

NVvR, NVVC

 

Acute management general principles:

  • Check and stabilize patient according to the ABCDE method
  • Stop infusing contrast agent and replace IV line with crystalloid.
  • Dyspnoea or stridor: let patient sit up
  • Hypotension: keep patient in prone position, raise legs
  • Consider measuring serum tryptase (see recommendations in chapter Laboratory Diagnosis of Hypersensitivity Reactions to Contrast Media)
  • Record acute allergic reactions in allergy registry (see chapter Organization of Healthcare)
  • Note: After administration of clemastine the patient may no longer be able (or insured) to drive a car/motorcycle or to operate machinery.

1 to 3 years

None

Lack of knowledge, lack of availability of drugs for treatment of acute reactions in rooms where CM is administered

Lack of knowledge, lack of availability of drugs for treatment of acute reactions in rooms where CM is administered

Spreading knowledge of guideline, development of local protocols for treatment of acute hypersensitivity reactions after CM

NVvR, NVVC

 

Severe reactions:

Cardiac or respiratory arrest:

  • Start CPR
  • Call the CPR team.

Anaphylactic reaction or stridor:

  • Call rapid response team (SIT-team)
  • Give oxygen 10-15L/min with non-rebreathing mask
  • Give 0.5mg adrenaline IM in lateral upper thigh
  • Give fluid bolus of crystalloid 500ml IV in 10 minutes, repeat as necessary.
  • Consider nebulizing with salbutamol 5mg or budesonide 2mg for stridor
  • Give clemastine 2mg IV
  • Consider adding corticosteroid (e.g. prednisolone 50mg iv, *)

1 to 3 years

None

Lack of knowledge, lack of availability of drugs for treatment of acute reactions in rooms where CM is administered

Lack of knowledge, lack of availability of drugs for treatment of acute reactions in rooms where CM is administered

Spreading knowledge of guideline, development of local protocols for treatment of acute hypersensitivity reactions after CM

NVvR, NVVC

 

Moderate reactions:

Consider transferring the patient to a department with facilities for monitoring of vital functions.

Isolated bronchospasm:

  • Salbutamol 2.5-5mg nebulization in oxygen by facemask 10-15 L/min (nebulization is easier to administer and more effective than dose aerosol).
  • In mild cases asthma patients may use their own salbutamol dose aerosol.
  • In case of deterioration give adrenaline 0.5mg IM and consider call rapid response team

Isolated facial oedema without stridor:

  • Give oxygen 10-15L/min via anon-rebreathing mask
  • Give clemastine 2mg IV
  • If oedema is severe or near airways or if stridor develops: treat as anaphylaxis

Isolated urticaria/diffuse erythema:

  • Give clemastine 2mg IV
  • If accompanied by hypotension: treat as anaphylaxis

Isolated hypotension:

  • Give bolus of crystalloid 500ml IV, repeat as necessary.
  • If accompanied by bradycardia, consider atropine 0.5mg IV
  • If accompanied by other symptoms: treat as anaphylaxis

1 to 3 years

None

Lack of knowledge, lack of availability of drugs for treatment of acute reactions in rooms where CM is administered

Lack of knowledge, lack of availability of drugs for treatment of acute reactions in rooms where CM is administered

Spreading knowledge of guideline, development of local protocols for treatment of acute hypersensitivity reactions after CM

NVvR, NVVC

 

Mild reactions:

General:

  • Mild reactions may only need reassurance
  • Observe vital signs until symptoms resolve
  • Do not remove iv access during observation

Consider:

  • Prescribing a non-sedating antihistamine, e.g. desloratadine 5mg PO (once daily) for mild allergic reactions
  • Ondansetron 4mg IV for protracted vomiting

1 to 3 years

None

Lack of knowledge, lack of availability of drugs for treatment of acute reactions in rooms where CM is administered

Lack of knowledge, lack of availability of drugs for treatment of acute reactions in rooms where CM is administered

Spreading knowledge of guideline, development of local protocols for treatment of acute hypersensitivity reactions after CM

NVvR, NVVC

 

1 Barriers can be found at multiple levels. They can exist at the level of the consultant, the hospital organisation, and the health care system.

2 Actions needed for implementation, but also actions to promote implementation. Think about checks during quality visits, guideline publication, information of hospital management, et cetera.

3 Who is responsible for implementation of recommendations will largely be determined by the level where the barriers are expected to be.