Imaging Pearls ❯ Contrast ❯ Contrast Reactions
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- Allergy: Patients who have had a prior allergic-like reaction or unknown-type reaction (i.e., a reaction of unknown manifestation) to contrast medium have an approximately 5-fold increased risk of developing a future allergic-like reaction if exposed to the same class of contrast medium again . A prior allergic-like or unknown type reaction to the same class of contrast medium is considered the greatest risk factor for predicting future adverse events. In general, patients with unrelated allergies are at a 2- to 3-fold increased risk of an allergic-like contrast reaction, but due to the modest increased risk, restricting contrast medium use or premedicating solely on the basis of unrelated allergies is not recommended. Patients with shellfish or povidone-iodine (e.g., Betadine®) allergies are at no greater risk from iodinated contrast medium than are patients with other allergies (i.e., neither is a significant risk factor) . There is no cross-reactivity between different classes of contrast medium. For example, a prior reaction to gadolinium-based contrast medium does not predict a future reaction to iodinated contrast medium, or vice versa, more than any other unrelated allergy.
ACR Manual On Contrast Media 2023 - Sickle-Cell Trait/Disease: Some have suggested that contrast medium exposure to patients with sickle cell trait or sickle cell disease might increase the risk of an acute sickle crisis; however, there is no evidence this occurs with modern iodinated or gadolinium-based contrast medium [11]. Therefore, restricting contrast medium use or premedicating solely on the basis of sickle cell trait or sickle cell disease is not recommended.
ACR Manual On Contrast Media 2023
- 24 vs 13 vs 5 Hour Contrast Prep
“Accelerated intravenous premedication with corticosteroids beginning 5 hours before contrast-enhanced CT has a breakthrough reaction rate noninferior to that of a 13- hour oral premedication regimen.”
Intravenous Corticosteroid Premedication Administered 5 Hours before CT Compared with a Traditional 13-Hour Oral Regimen Benjamin M. Mervak et al. Radiology (in press) - “Our data support the replacement of a 13-hour oral premedication regimen with a 5-hour intravenous premedication regimen in patients with competing medical priorities (eg, inpatients, those in emergency departments).”
Intravenous Corticosteroid Premedication administered 5 hours before CT compared with a Traditional 13-hour Oral regimen Mervak PM et al. Radiology 2017; 285:425–433 - “Faster premedication should reduce the indirect harms of pre- medication in hospitalized patients at high risk for reactions to contrast media.”
Intravenous Corticosteroid Premedication administered 5 hours before CT compared with a Traditional 13-hour Oral regimen Mervak PM et al. Radiology 2017; 285:425–433
- “The overestimation of overall risk and consequences of intravenous contrast media-induced nephropathy has perpetuated an unwarranted avoidance of contrast-enhanced studies with consequent reduction in effectiveness of management of a number of genitourinary diseases. Properly assessing the risk of contrast nephropathy and avoiding this common imaging pitfall is critical in avoiding or misdiagnosing otherwise treatable genitourinary pathology.”
Overestimating the Risk of Intravenous Contrast Medium-Induced Nephropathy: A Pitfall in Imaging the Genitourinary System Lyndon L, Newhouse JH Seminars in Roentgenology (in press) - “Contrast-induced nephropathy (CIN) is typically defined as an absolute or percentage increase in serum creatinine (SCr) level over baseline; 0.5 mg/dl is the commonest threshold for an absolute rise; 25%, 50% and 100% have all been used in published series dealing with CIN.”
Overestimating the Risk of Intravenous Contrast Medium-Induced Nephropathy: A Pitfall in Imaging the Genitourinary System Lyndon L, Newhouse JH Seminars in Roentgenology (in press) - “It should be immediately obvious from the above that in the conditions which may be missed or mischaracterized if contrast is withheld, appropriate patient management can be severely impeded in a number of ways. And the problem is wider: a great deal of GU disease is discovered incidentally on CT scans initially performed for other problems. If contrast is unnecessarily withheld from abdominal CT performed for any reason, significant errors in GU diagnoses may ensue.”
Overestimating the Risk of Intravenous Contrast Medium-Induced Nephropathy: A Pitfall in Imaging the Genitourinary System Lyndon L, Newhouse JH Seminars in Roentgenology (in press) - “We conclude, therefore, that many essential CT examinations requiring contrast are withheld due to an unwarranted fear of nephropathy and its associated risks with consequent reduction in effectiveness of management of a number of GU and other diseases. This practice constitutes a sufficient threat to health that serious attempts to correct it are warranted.”
Overestimating the Risk of Intravenous Contrast Medium-Induced Nephropathy: A Pitfall in Imaging the Genitourinary System Lyndon L, Newhouse JH Seminars in Roentgenology (in press) - “Within radiology departments, policy constraints for intravenous contrast administration should be reviewed and liberalized where possible, and policies which strictly forbid contrast administration should be replaced by requirements for realistic comparisons of the risk of nephropathy with the risk of incorrect diagnosis. Radiologists should also address the need to educate our referring colleagues about the real level of risk. We owe our patients nothing less..”
Overestimating the Risk of Intravenous Contrast Medium-Induced Nephropathy: A Pitfall in Imaging the Genitourinary System Lyndon L, Newhouse JH Seminars in Roentgenology (in press)
- “The predictive value of specific allergies, such as those to shellfish or dairy products, previously thought to be helpful, is now recognized to be unreliable. A significant number of health care providers continue to inquire specifically into a patient’s history of “allergy” to seafood, especially shellfish. There is no evidence to support the continuation of this practice.”
ACR Manual on Contrast Media
Version 9 (2013) - “Patients with significant cardiac disease may be at increased risk for contrast reactions. These include symptomatic patients (e.g., patients with angina or congestive heart failure symptoms with minimal exertion) and also patients with severe aortic stenosis, primary pulmonary hypertension, or severe but well-compensated cardiomyopathy. In all such patients, attention should be paid to limiting the volume and osmolality of the contrast media.”
ACR Manual on Contrast Media
Version 9 (2013)
- “ Delayed Adverse Reactions to contrast media are not rare but are often not recognized as being linked to contrast administration and may be falsely ascribed to other drugs, These side effects are problematic because the patient is usually without medical supervision.”
Delayed Adverse Reactions to Parental Administration of Iodinated Contrast Media
Egbert RE et al.
AJR 2014; 203:1163-1170 - “ Immediate reactions occur at the time of injection to 1 hour after contrast administration, with most occurring within the first 5 minutes. These reactions may be either allergiclike or chemotoxic.”
Delayed Adverse Reactions to Parental Administration of Iodinated Contrast Media
Egbert RE et al.
AJR 2014; 203:1163-1170 - “ Delayed reactions are defined as an adverse event occurring from more than 30-60 minutes to 1 week after the administration of contrast media. The majority of these reactions have been shown to occur between 6 and 12 hours after contrast administration.”
Delayed Adverse Reactions to Parental Administration of Iodinated Contrast Media
Egbert RE et al.
AJR 2014; 203:1163-1170 - “ The ACR states that most cases of DARs are self limited and require no or minimal treatment. In cases of moderate or severe reactions that are progressive or widespread the ACR recommends antihistamines, corticosteroids, or both for skin manifestations; antipyretics for fever; antiemetic's for nausea; and fluid resuscitation for hypotension.”
Delayed Adverse Reactions to Parental Administration of Iodinated Contrast Media
Egbert RE et al.
AJR 2014; 203:1163-1170
- “Amongst the respondents, 66% routinely asked about a previous history of shellfish/iodine allergy. Fifty-six percent would pre-treat these patients with steroids and anti-histamines. The other 44% do nothing, or do nonspecific testing based on their personal experience as following: (1) Skin test with 1 mL of subcutaneous contrast before intravenous contrast; (2) Test dose 2 mL contrast before coronary injection; (3) Close observation for shellfish allergy patients; and (4) Minimal evidence that the steroid and anti-histamine regime is effective but it makes us feel better.”
Shellfish allergy and relation to iodinated contrast media: United Kingdom survey.
World J Cardiol. 2014 Mar 26;6(3):107-11
Baig M et al. - “There is no evidence that allergy to shellfish alters the risk of reaction to intravenous contrast more than any other allergy and asking about such allergies in pre-angiogram assessment will not provide any additional information except propagating the myth.”
Shellfish allergy and relation to iodinated contrast media: United Kingdom survey.
World J Cardiol. 2014 Mar 26;6(3):107-11
Baig M et al.
- “ The results suggest that premedication of patients with a history of urticaria after LOCM may not be necessary.”
Premedication of patients for prior urticarial reaction to iodinated contrast media
Kolbe AB et al.
Abdom Imaging (2014) 39:432-437 - “ Given the results of this study, our radiology department implemented a practice guideline stating premedication of patients having a prior hives reaction is not required.”
Premedication of patients for prior urticarial reaction to iodinated contrast media
Kolbe AB et al.
Abdom Imaging (2014) 39:432-437 - “ Given the results of this study, our radiology department implemented a practice guideline stating premedication of patients having a prior hives reaction is not required. Use of premedication is, of course, left to the discrimination of the referring physician and performing radiologist after review of the patients symptoms and severity.”
Premedication of patients for prior urticarial reaction to iodinated contrast media
Kolbe AB et al.
Abdom Imaging (2014) 39:432-437
"Adverse reactions to intravenous administration of a nonionic contrast material (ioversol) are rare in children and increase in frequency with advancing age. The great majority of reactions in children are mild."
Nonionic Iodinated Intravenous Contrast Material-related Reactions:Incidence in Large Urban Children’s Hospital-Retrospective Analysis of Data in 12,494 Patients
Callahan MJ et al.
Radiology 2009; 250:674-681"The incidence of contrast material reactions (per 1000 studies) is lowest in young children and increases to adult levels with advancing age of the child."
Nonionic Iodinated Intravenous Contrast Material-related Reactions:Incidence in Large Urban Children’s Hospital-Retrospective Analysis of Data in 12,494 Patients
Callahan MJ et al.
Radiology 2009; 250:674-681"Incidence of a type I (mild) contrast material reaction was 0.38% or 1 in 250 patients.Incidence of a type II (moderate) reaction was 0.08% or 1 in a 1000 patients.There were no severe (type III) reactions."
Nonionic Iodinated Intravenous Contrast Material-related Reactions:Incidence in Large Urban Children’s Hospital-Retrospective Analysis of Data in 12,494 Patients
Callahan MJ et al.
Radiology 2009; 250:674-681"Breakthrough reactions are usually similar in severity to the index reaction and subsequent contrast medium injections usually do not induce repeat breakthrough reactions. Breakthrough reactions are more likely to be moderate or severe in patients with certain risk factors."
Repeat Contrast Medium reactions in Premedicated Patients: Frequency and Severity
Davenport MS et al.
Radiology 2009; 253:372-379"Breakthrough reactions were significantly more likely to be moderate or severe in patients with a history of chronic oral corticosteroid use, drug or severe allergies, or allergies to four or more allergens."
Repeat Contrast Medium reactions in Premedicated Patients: Frequency and Severity
Davenport MS et al.
Radiology 2009; 253:372-379"The majority (174 of 197 or 88%) of low osmolality contrast medium (LOCM) injections in the premedicated patients with a prior breakthrough reaction did not result in a repeat breakthrough reaction."
Repeat Contrast Medium reactions in Premedicated Patients: Frequency and Severity
Davenport MS et al.
Radiology 2009; 253:372-379"The severity, signs, and symptoms of a breakthrough reaction are most often similar to those of the index reaction."
Repeat Contrast Medium reactions in Premedicated Patients: Frequency and Severity
Davenport MS et al.
Radiology 2009; 253:372-379"Patients with a mild index reaction have an extremely low risk of a severe breakthrough reaction. Patients with a moderate or severe index reaction are at high risk of experiencing another moderate or severe reaction should a breakthrough reaction occur."
Repeat Contrast Medium reactions in Premedicated Patients: Frequency and Severity
Davenport MS et al.
Radiology 2009; 253:372-379"This regimen (premedication regimen) consists of 50 mg prednisone taken 13 hours, 7 hours and 1 hour before the imaging examination combined with 50 mg of diphenhydramine taken 1 hour before the examination."
Repeat Contrast Medium Reactions in Premedicated Patients: Frequency and Severity
Davenport MS et al.
Radiology 2009; 253:372-379- "Allergic type reactions in 545 (O.6%) of patients injected with nonionic contrast media: 418 (77%) reactions were mild, 116 (21%) were moderate, and 11 (2%) were severe."
Frequency, Outcome and Appropriateness of Treatment of Nonionic Iodinated Contrast Media Reactions
Wang CL et al
AJR 2008;191:409-415 - "Allergic type reactions in 545 (O.6% of 84,928 studies) of patients injected with nonionic contrast media: 418 (77%) reactions were mild, 116 (21%) were moderate, and 11 (2%) were severe. 221 patients (41%) received treatment. "
Frequency, Outcome and Appropriateness of Treatment of Nonionic Iodinated Contrast Media Reactions
Wang CL et al
AJR 2008;191:409-415 - "Allergic type reactions in 545 (O.6%) of patients injected with nonionic contrast media: 418 (77%) reactions were mild, 116 (21%) were moderate, and 11 (2%) were severe. 221 patients (41%) received treatment. "
Frequency, Outcome and Appropriateness of Treatment of Nonionic Iodinated Contrast Media Reactions
Wang CL et al
AJR 2008;191:409-415 - "Patients usually do well after developing acute allergic like reactions to nonionic iodinated contrast media. Fortunately, in our series, this was true even in the rare cases in which the instituted treatment was considered to be inappropriate. Reacting patients rarely develop long term sequela."
Frequency, Outcome and Appropriateness of Treatment of Nonionic iodinated Contrast Media Reactions
Wang CL et al.
AJR 2008; 191:409-415 - Predisposing risk factors for general acute adverse reactions to contrast media
- Previous adverse reactions
- History of asthma
- History of allergy
- Heart disease
- Dehydration
- Hematological conditions like sickle cell anemia, polycythemia and myeloma - Predisposing risk factors for general acute adverse reactions to contrast media
- Pre-existing renal disease
- Infants and the elderly
- Anxiety
- Beta blockers, NSAIDs, interleukin 2
- Adverse reactions to Intravenous Iodinated Contrast Media: A Primer for Radiologists Namasivayam S et al. Emerg Radiol (2006)12; 210-215 - How often do contrast reactions occur?
- Mild acute reactions occur in up to 3% of patients receiving non-ionic contrast
- Moderate reactions occur in 0.2-0.4% of patients receiving non-ionic contrast
- Severe reactions occur in 0.04% of patients receiving non-ionic contrast
- Adverse reactions to Intravenous Iodinated Contrast Media: A Primer for Radiologists Namasivayam S et al. Emerg Radiol (2006)12; 210-215 - Is it possible for a patient to get a delayed reaction to IV contrast?
- The answer is yes. "A delayed reaction is defined as a reaction which occurs 1 hour to 1 week after contrast injection, which is predominately skin reaction. Iso-osmolar non-ionic contrast media have higher incidence of delayed adverse reactions."
- Adverse reactions to Intravenous Iodinated Contrast Media: A Primer for Radiologists Namasivayam S et al. Emerg Radiol (2006)12; 210-215 - What are the categories of contrast reactions?
Three Categories
- Mild
- Moderate
- Severe - Mild Reactions Include
- Nausea and vomiting
- Cough
- Warmth
- Headache
- Itching
- Flushing
- Mild rash or hives - Moderate reactions include
- Tachycardia or bradycardia
- Hypertension
- Hypotension
- Dyspnea
- Bronchospasm or wheezing
- Severe skin rash or hives - Severe reactions include
- Laryngeal edema
- Convulsions
- Profound hypotension
- Arrthymias
- Unresponsiveness
- Cardiopulmonary arrest
- (severe reactions are considered life threatening) - "Acute allergic-like reactions to IV administration of low-osmolality nonionic iodinated contrast material in children are rare. As in the adult population, most pediatric reactions are mild; however severe reactions do occur."
Incidence and Severity of Acute Allergic-Like Reactions to IV Nonionic Iodinated Contrast Material in Children
Dillman JR et al.
AJR 2007; 188:1643-1647 - "Acute allergic like reactions to contrast material were documented in 20 (0.18%) of the patients. Sixteen (80%) of the acute allergic like reactions were categorized as mild, one as moderate (5%) and three (15%) as severe. No deaths were attributed to IV nonionic contrast material."
Incidence and Severity of Acute Allergic-Like Reactions to IV Nonionic Iodinated Contrast Material in Children
Dillman JR et al.
AJR 2007; 188:1643-1647