Who Can Administer IV Contrast? 3

INTRAVENOUS

PROTOCOL

RADIOLOGY

2012/13

CONTENT PAGES

Who can administer IV contrast? 3

Prior to injection 5

Iodinated IV contrast media injections 5

During the injection 5

After the injection 6

Equipment 7

Safety check carried out 7

Who can peripherally cannulate patients? 8

Preparation prior to needle insertion/ANTT 9

The insertion of venflon 10

For needle stick injury 12

Allergy protocol questionnaire 13

Emergency drugs/procedure 14

List of trained injectors 15

Appendix: RCR 2010 guidelines 16

Protocol for radiographers

Who can administer IV Contrast?

Radiographers who:

·  Hold a certificate of competence in the administration of IV injections which is certified by the College of Radiographers.

·  Have completed a record of clinical competency in 25 injections under supervision as required by The Hillingdon Hospital NHS Trust and been assessed by an appropriate member of the Radiology team.

·  Have been included on the internal IV cannulation register held in the Management Office/ CT scanner.

·  Have received training specific to the mode of delivery. E.g. injector pumps in CT, MR or hand injection for IVU.

Radiographers may only inject during normal working hours when a radiologist is present in the department.

Radiographers undertaking injections must be aware of their level of competence and not work beyond it.

Radiographers are responsible for explaining the examination to the patient including the reason for the intravenous injection.


Radiographers must not inject in the following circumstances:

·  Paediatric cases (from the age of 0 yrs to below 18yrs).

·  Patients with a previous allergic reaction.

·  Patients in renal failure or with significant dehydration.

·  Patients with asthma or history of allergy.

·  Diabetic patients on metformin.

·  Out of hours. The requirement to give contrast will be discussed by the referring team with the on call radiologist. If contrast is to be administered it is the responsibility of the accompanying Doctor (SHO grade or above) to give hand injections and to be present if the pump is the chosen mode of delivery

The following patients may receive IV contrast in CT once a radiologist has agreed to proceed and signed the contrast allergy check list:

·  Patients with a previous allergic reaction

·  Patients with renal failure of significant dehydration

·  Patients with asthma or history of allergy

·  Diabetic patients on Metformin

Radiographers must follow the agreed procedure as described below:

·  Prior to injection.

·  During the injection.

·  After the injection.


PRIOR TO INJECTION:

The patient’s identity must be verified using the three point departmental ID procedure.

·  If the patient is an outpatient, check identity by asking him/her to state his/her full name, date of birth and address.

·  If the patient is from the ward, check patient has a wristband with full name and date of birth. In addition, identity must be verified with patient as above if at all possible.

FOR IODINATED IV CONTRAST INJECTIONS:

CT & IVU:

The allergy check-list for contrast media must be filled in by the patient, signed by the patient, and counter-signed by the radiographer who will be administering the IV injection. If there are any questions answered as “Yes”, a radiologist must be consulted, who will also need to countersign the contrast allergy check list before the radiographer proceeds. Contrast, dose and imaging is to follow a protocol decided by a covering radiologist.

For IVUs, the radiographer must take the previously vetted request form, control image and the completed allergy questionnaire to a radiologist who will decide:

·  Whether to proceed with the examination.

·  What contrast/ dose is to be given.

·  What imaging series is to be performed?

The blood results for creatinine and eGfr must be included on the allergy check list.

DURING THE INJECTION:

·  Only approved personnel, who have knowledge of the side effects and adverse reactions to contrast, may perform the injection.

·  Staff must have basic life support training and an up to date in-house training certificate.

·  The injection in respect of type, concentration, expiry date, volume and dose MUST be double-checked by a second healthcare practitioner/ clinician and recorded.

·  A second person must remain with, or monitor the patient for at least 10 minutes after the injection. A patient should not be left alone or unsupervised in the first 5 minutes after injection of contrast, (RCR -Standards for iodinated intravascular contrast agent administration to adult patients ( second edition). 2010

·  A maximum of two attempts to insert the cannula may be made. If this is unsuccessful, assistance must be sought.

·  For radiographic contrast media, once cannulation is successful, the cannula should be left in place, unless otherwise instructed.

·  The ANTT guidelines for the trust (shown below) must be adhered to for all cannulations.

AFTER THE INJECTION:

After injection, the cannula should remain in situ for 15 minutes post injection of contrast media. Before the patient is sent home, the radiographer must:

·  Make the patient aware of any side effects that may occur and provide information regarding who they can contact, if such an occasion arises.

·  It is advisable that the patient remains on the premises for at least 15 minutes after the injection. Most severe reactions occur within this timeframe. In patients with increased risk of a reaction, this should increase to 30 minutes. It is advised that, in these cases, the cannula is kept in place and the patient is observed for 30 minutes. (RCR -Standards for iodinated intravascular contrast agent administration to adult patients ( second edition). 2010)

If the patient is an inpatient arrange for them to be returned to the ward. If they are an outpatient:

·  Make sure the cannula has been removed and disposed of correctly.

·  Clean the area of the injection and cover with a dressing.


IV PROTOCOL

EQUIPMENT

·  CONTRAST MEDIA – Iodinated contrast agent

Check content intact/expiry date not exceeded.

·  RANGE OF VENFLONS (to be use in the administration of all contrast media).

Check packaging intact and expiry date.

·  SKIN PREPARATION SWABS. (ALCOHOL)

·  TOURNIQUET.

·  TAPE - MICROPORE / TRANSPORE/TEGADERM.

Check for allergies.

·  NORMAL SALINE FLUSH IF REQUIRED.

Check packaging and expiry date.

·  Syringes - variety of measures.

·  GAUZE SWAB

All of the above should be placed on a convenient tray. Hands must be washed and gloves worn.

SAFETY CHECK THAT MUST BE CARRIED OUT AS STANDARD PROCEDURE:

·  Expiry dates of all contrast agents and equipment used.

·  Correct contrast agent and concentration. (Check with radiologist or dept guidelines).

·  No air bubbles in syringe or connecting tube.

·  Safe disposal of waste and sharps.

·  Check location and content of emergency drug box.

·  LMP of women of child bearing age.

·  Allergies checked and Allergy Form filled out prior to giving any contrast.

Who can peripherally cannulate a patient?

Radiographers who:

·  Hold a certificate of competence in the administration of IV injections which is certified by the College of Radiographers.

·  Have been included on the internal IV cannulation register held in the Management Office.

·  Have completed the Aseptic non touch technique training in line with trust policy on peripheral cannulation. To have passed the formal assessment of ANTT. Register of trained personnel kept in Nurses Office.

Under the ANTT/Infection control policy only outpatients attending for their scans can be cannulated by a suitably qualified radiographer. No inpatients are to be cannulated by radiographers.

Preparation prior to Peripheral Cannulation

·  Ensure patient is relaxed and explain procedure prior to beginning.

·  Allow adequate time for inspection and palpation of the patient’s forearm and dorsum of hand to select site. Select appropriate cannula in regards to:

·  Size, state of patient, blood flow of available vein should be considered.

·  Cannula /needle length should correspond appropriately to the length of the straight vein to be punctured.

·  Injection rate – high rates will require a large vein.

·  The ANTT guidelines shown below should be followed systematically from number 1 through to 18.

·  Tourniquet is applied proximally to intended injection site – this should be done gently making sure the skin is not pinched or that the tourniquet is not too tight. Over tightening can impair arterial flow to the limb and cause underfilling of the veins.

THE INSERTION:

For all contrast media injections only venflons are to be use for mode of delivery.

·  Fold down the wings of the venflon.

·  Hold the venflon firmly with a 3-point grip, which minimises the risk of contaminating the luer connection, and ensures a correct position between the needlepoint and the catheter tip.

·  Insert the cannula into the vein at a low angle.

·  Once the needle is correctly inserted, blood will be seen in the flash back chamber of the cannula. The flow control plug stops the flow of blood.

·  Advance the cannula a few millimetres further into the vein – this ensures that the catheter tip also enters the vein (check for a haematoma).

·  Withdraw the needle partially to avoid exit through the posterior vein wall.

·  Firmly hold the flash chamber to immobilise the needle.

·  Advance the catheter off the needle into the vein.

·  Release the tourniquet.

·  The needle must never be reinserted while the catheter is in the vein, as this may puncture or sever the tip of the catheter.

·  Avoid blood spillage by pressing a finger on the vein on or above the catheter tip, withdraw the needle completely.

·  Attach the infection control approved Viagon bionector 2 bung (has no connecting tube).

·  Tape the wings securely to the patient’s skin (this is important as movement may result in mechanical irritation of the vein).

·  Verify the correct placement of the venflon using normal saline flush (check to see if any tissueing or haematoma has occurred).

·  At the end of the examination, or when entrance to the vein is no longer required, withdraw the cannula swiftly. Then press on to the site for several moments using a gauze swab to help prevent bruising/bleeding, and protect site by securing the swab with micropore tape.

·  Safely dispose of the needle into a sharps box. Gloves must be discarded in a yellow clinical waste bag.

·  Wash hands.

It is reasonable to make two attempts at venepuncturE on patients before seeking help from a colleague. This may be reduced to one attempt in sensitive and/or frightened patients.


FOR NEEDLE STICK INJURY FOLLOW THE HOSPITAL PROTOCOL:

Ø  Squeeze puncture site.

Ø  Wash the area under running water.

Ø  Seek help from Occupational Health/A/E Department.

Ø  Fill in an incident form & report to manager.

Ø  Record the name of the patient, the date and time of the examination.

Ø  Blood samples from the patient and person concerned will be taken and reviewed again after 6 months.

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M:\Radiology\Protocols and Policies\Radiography\IV CONTRAST PROTOCOL 2012/13.doc

Updated 11/07/2012Paula Merry/Jagit Saund./Graham Smith.

ID Check 1 / ID Check 2 / Wrist Band Check

ALLERGY CHECKLIST FOR CONTRAST MEDIA

To be completed prior to IV administration of contrast media when given by radiographers. The patient along with either the radiographer or the supervising radiologist must sign the form.

Patient Name: ______Date: ______

Hospital No: ______Date of Birth: ______

Yes / No
Have you ever had an X-ray procedure involving an injection of ‘x-ray dye’?
If so did you have any nausea/vomiting or allergic type reaction to the injection?
Are you allergic to Iodine or foods containing iodine such as Seafood?
Have you had an allergic reaction to any specific drugs, chemicals or foods?
(i.e. Antibiotics, elastoplasts, nuts, strawberries, latex)
If so please list below
Do you or have you ever suffered from the following?
i. Asthma (If so please bring your medication with you when you come for your CT scan)
ii. Hayfever
iii. Eczema
iv. Heart Disease
v. Glaucoma
vi. COPD or Emphysema (CT pneumocolons)
vii. Sickle Cell Anaemia
Do you have diabetes?
If so what medication do you take for your diabetes?
If you are being treated with METFORMIN (Glucophage) please do not take this medication on the day of your scan.
Have you ever had any problems with your kidneys?
If so please ring CT appointments on 01895 279326.

FOR OFFICE USE

Date / Serum Urea / Serum Creatinine / eGFR

Patient signature: ______Radiographer Signature: ______

Proceed with Exam: YES/NO Radiologist signature: ______

eMERGENCY EQUIPMENT

The following equipment must be accessible, where contrast injections are given.

The availability must be checked before starting a procedure:

·  Oxygen and mask.

·  Suction, with tubing and suction catheter attached.

·  A selection of syringes, needles, gloves and swabs.

·  Know the location of emergency drugs and the resus trolley.

EMERGENCY DRUGS

The following may be required in the event of a contrast media reaction:

·  Epinephrine (adrenaline) 1:1,000 / ·  Epinephrine (adrenaline) 1:10,000
·  Hydrocortisone 100mg / ·  Metrochlopromide 10mg in 2ml
·  Chlorpheniramine 10mg (piriton) / ·  Frusemide 20mg
·  Sodium chloride 0.9 % / ·  Water for injection
·  Salbutamol 2.5mg nebules / ·  Nebuliser with connector
·  Adult and child mask / ·  Atropine sulphate 1mg in 10ml

All of the above drugs can be found on a tray in CT or in the drugs cupboard in the Nursing Office. In the event of an emergency these may be required in the room.

There are two resus trolleys with defibrillators.

·  Two located in the recovery area one, with paediatric accessories (next to MRI)

·  One located in the CT scanner room.

In event of an emergency get help, ring the crash number 2222. State the area you are located/the emergency (adult or paediatric), and the room you are in. Then start resuscitation procedure until help arrives.

(Follow trust protocol).


LIST OF TRAINED INJECTORS

RADIOGRAPHERS INJECTING / cOMPLETED
IN HOUSE
TRAINING / date / cOMPLETED
EXTERNAL
TRAINING / date

Copies of CoR certificates to Paula Merry for the IV cannulation register.

APPENDIX:-

RCR -Standards for iodinated intravascular contrast agent administration to adult patients (second edition). 2010 can be found following this link: http://www.rcr.ac.uk/docs/radiology/pdf/BFCR(10)4_Stand_contrast.pdf

Hard copies kept in CT and Rooms 4/5

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M:\Radiology\Protocols and Policies\Radiography\IV CONTRAST PROTOCOL 2012/13.doc

Updated 11/07/2012Paula Merry/Jagit Saund./Graham Smith.