Reason for making this guideline

The Radiological Society of the Netherlands (Nederlandse Vereniging voor Radiologie/NVvR) deemed a set of new guidelines on the Safe Use of Contrast Media (CM) highly necessary and relevant. In radiology, contrast media, such as Iodine-based Contrast Media (ICM) and Gadolinium Based Contrast Agents (GBCA), are extensively used. The overall goal of this set of guidelines was to increase safety and awareness around contrast media. Practical recommendations are given in each chapter.

The four parts of the Safe Use of Contrast Media guidelines cover the following topics regarding CM safety:

Safe Use of Contrast Media - Part 1 (finalized in 2017):

• Prevention of contrast-associated acute kidney injury (CA-AKI*) from iodine-based contrast media
• Iodine-based contrast media use in patients with type-2 diabetes taking metformin
• Iodine-based contrast media use in patients on chronic dialysis

Safe Use of Contrast Media - Part 2 (finalized in 2019):

• Prophylaxis and management of hypersensitivity reactions to contrast media
• Safe use of gadolinium-based contrast agents, in terms of prevention of post-contrast acute kidney injury (PC-AKI) and Nephrogenic systemic fibrosis (NSF)
• Contrast media injections with power injectors through (peripherally inserted) central venous lines and implantable ports
• Contrast media extravasation

Safe Use of Contrast Media - Part 3 (finalized in 2022):

• Prevention of iodine-induced hyperthyroidism
• Safe use of contrast media use during pregnancy and lactation
• Safe use of contrast media use in patients with rare diseases:
  • Patients with Multiple Myeloma (M. Kahler)
  • Patients with Pheochromocytoma and Paraganglioma
  • Patients with Myasthenia Gravis
  • Patients with Mastocytosis
• Safe time intervals between contrast-enhanced studies
• Prevention of recurrent hypersensitivity reactions to contrast media (update of part 2), including the Weber and Lalli effects
• Analytical Interference of contrast media with clinical laboratory tests
• Gadolinium deposition in the body after gadolinium-based contrast agents (both update of part 2 and a new module about strategies for GBCA dose reduction)

Safe Use of Contrast Media - Part 4 Children (finalized in 2024):

• Risk stratification in the Prevention of Post Contrast Acute Kidney Injury (PC-AKI)

• Hydration Strategies in the Prevention of PC-AKI

• Profylactic Measures for Hypersensitivity Reactions

• Treatment of Acute hypersensitivity reactions

• Monitoring of Thyroid Function after Administration of Iodine-based Contrast Media

*Note: Post-contrast acute kidney injury is synonymous with contrast-associated acute kidney injury Guideline Safe Use of Contrast Media part 4 Guideline for Authorisation phase June 2024.

Aim of the current guideline

The aim of the Safe Use of Contrast Media guidelines is to critically review the recent evidence and try to formulate new practical guidelines for all hospital physicians to provide the safe use of contrast media in diagnostic and interventional studies in children (younger than 18 years) and adults (18 years and older). The ultimate goal of this guideline is to increase the quality of care, by providing efficient and expedient healthcare to children that may benefit from this healthcare and simultaneously guard patients from ineffective care. Furthermore, such a guideline should ideally be able to save money and reduce day-hospital waiting lists.

Focus of the guideline

The Safe Use of Contrast Media guidelines focus on all child (younger than 18 years) and adult (18 years and older) patients that receive CM during radiologic or cardiologic studies or interventions. The patient population for which these guidelines are developed are patients who receive intravascular, oral or intracavitary (intra-articular, intra-vesical, intra-cholangiographic) contrast media both in the clinical setting, as well as for outpatients. The guidelines do not cover radiopharmaceuticals used in nuclear medicine.

Users of this guideline

This guideline is intended for all hospital physicians that request or perform diagnostic or interventional radiologic or cardiologic studies for their patients in which CM are involved.

For children and their caretakers

The modules for children under the age of 18 are specifically designed for a relatively vulnerable patient group. Besides the child who sometimes has to undergo additional blood collections and procedures, the parents/caretakers also need to be informed about and consent to the necessary measures.

Patients and parents/caretakers want to make decisions based on the available evidence and best clinical practice. This emphasizes the importance of comprehensive and understandable information and the management of patient and parent/caretaker anxiety that can arise when using this guideline.

Keeping patient and parents/caretakers informed in a calm atmosphere, will eventually reduce stress and anxiety.

Terminology and definitions

The terminology and definitions of specific topics will be discussed in each of the specific topics/modules of this guideline. Abbreviations used in this guideline can be found below.

Guideline Disclaimers

General

The aim of clinical guidelines is to help clinicians to make informed decisions for their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgement, knowledge and expertise. A guideline cannot replace a physician’s judgment in diagnosing and treatment of particular patients.

Guidelines may not be complete or accurate. The guideline development group and members of their boards, officers and employees disclaim all liability for the accuracy or completeness of a guideline, and disclaim all warranties, express or implied to their incorrect use.

Guidelines users are always urged to seek out newer information that might impact the diagnostic and treatment recommendations contained within a guideline.

Individualisation

In specific high-risk patient groups clinicians may have to regress from these general guidelines and decide on individualisation to best fit the needs of their patients.

Life-threatening situations or conditions

In acute life-threatening situations or conditions clinicians may have to regress from these general guidelines and decide on individualisation to best fit the needs of their patients in these situations or conditions.

Documentation

The guideline development group recommends documenting the specific contrast medium name and dose which were administered to the patient (in the imaging report and/or with the stored images).