Guidelines for IV contrast media use, management in pediatric patients

A survey of a subset of Society of Pediatric Radiology (SPR) members provided the foundation for guidelines for clinical histories necessary before IV contrast media, maximum IV contrast injection rates for standard angiocatheters, contrast media injection rates for specific CT studies and management of IV contrast media soft-tissue extravasation, according to a study published in the April issue of American Journal of Roentgenology.

Though iodinated IV contrast media is often used for pediatric CT studies, few guidelines exist on appropriate administration. Lead author Michael J. Callahan, MD, of Boston Children’s Hospital, and colleagues distributed an anonymous web-based survey to investigate the practice patterns of SPR members in their use of iodinated IV contrast media for pediatric CT. They hoped to create a point of reference for practice development and modification for all radiologists.

After distributing a 15-question survey to 1,545 members, the researchers had a 6 percent response return rate. These 88 respondents represented 26 percent of the SPR membership. Most respondents thought that IV contrast media administration (97 percent), renal insufficiency (97 percent), current metformin use (72 percent), significant allergies (61 percent), diabetes (54 percent) and asthma (52 percent) were pieces of clinical information mandatory before administration.

Most participants administered contrast media through nonimplanted central venous catheters (78 percent), implanted venous ports (78 percent) and peripherally inserted central catheters (72 percent).

IV contrast medium injection rates were most commonly maxed at 5 mL/s or more for a 16-gauge angiocatheter, 4 mL/s for an 18-gauge angiocatheter, 3 mL/s for a 20-gauge angiocatheter and 2 mL/s for a 22-gauge.

Ninety-five percent of participants elevated the affected extremity after soft-tissue extravasation of IV contrast media, while 76 percent used ice and 45 percent used heat.

“At a minimum, we suggest that the following clinical information should be obtained before the administration of iodinated IV contrast media in children: history of allergy to iodinated IV contrast media, history of severe allergies or atopy to other allergens, history of renal insufficiency, and current use of metformin-containing medication,” wrote Callahan and colleagues.

“Other clinical information could be obtained at the discretion of the individual practice or institution. A history of, or a potential for, sickle cell disease or sickle cell crisis, pheochromocytoma, myasthenia gravis, diabetes mellitus, or medical history of asthma might be clinically useful in certain patients, but a history of one of these disease processes should not affect a radiologist's decision to administer iodinated IV contrast media for a clinically indicated CT study,” they continued.

The authors also recommended maximum IV contrast media injection rates for the pediatric demographic as 5 mL/s for 16- to 18-gauge angiocatheters, 4 mL/s for 20-gauge, 2.5 mL/s for 22-gauge and 1 mL/s for 24-gauge angiocatheters.

They suggested an initial clinical evaluation and examination by a radiologist after soft-tissue extravasation of IV contrast media. If the extravasated media is believed to be clinically significant, the affected extremity should be raised and an ice pack should be used.

“Because most pediatric patients are imaged at adult-based radiology practices, we hope that this article will serve as a general guideline for those adult radiologists who occasionally image children and will provide some direction for the effective use of iodinated IV contrast media and management of IV contrast media extravasation for CT studies in children,” they concluded.