UNIT PROJECT
It only takes one anaphylactic reaction to realize that you need
to have emergency medications close at hand. IV contrast reactions
can vary from mild to severe and life threatening. The incidence of
contrast reactions in Radiology are as follows:
 3% of patients receiving contrast will have a reaction
and require no treatment.
 0.4% of patients receiving contrast will have a moderate
reaction and require treatment.
 0.04% of patients receiving contrast will experience a
severe (life-threatening) reaction. (Duncan, K. (December
6, 2012). Webinar, Anaphylaxis What’s Going On?).
Although anaphylactic reactions are rare, it can be deadly when it
does happen. We had a very serious contrast reaction in CT that
resulted in anaphylaxis. Luckily the patient did go home.
A patient that had a known contrast reaction had been premedicated with the standard thirteen hour prep, which includes
Prednisone and Benadryl. Patients who are at higher risk include
those with past reactions to contrast media (up to 44%); those with
asthma; those who have a history of heart and kidney and thyroid
(both hypo- and hyperthyroidism) diseases; those taking beta –
blockers or metformin; and females and the elderly (appear to be at
higher risk for severe reactions). (Center LM. Anaphylactoid
reactions to radiocontrast media. Allergy Asthma Proc.
2005;209:189-192.) (Keller DM, Iodinated contrast media raises risk
of thyroid dysfunction. Arch Intern Med. 2012;172:153-159)
Immediately after the scan the patient was itching and had a rash.
The patient was deteriorating quickly. The patient went into
respiratory arrest and the nurse began respiratory support. The
physician ordered Epinephrine (EPI) and the CT techs did not know
exactly what the physician wanted. After this event is when Dr.
Restauri and I realized that we needed an easier and faster way to
get to EPI in an urgent situation.
I mentioned to Dr. Restauri that at my previous hospital, we
had an emergency box in every room on the wall. The one thing that
Dr. Restauri insisted upon in this box was an EpiPen. Not only is it
easily accessible but it is also premeasured. In an emergent
situation, this saves critical time and prevents errors. However,
getting approval for the EpiPen took some work. It is expensive and
would not be used often. It is one of those times when if you have it
you will not need it but if you do not have it you will need it. It took
months of attending the Radiology Quality meetings, Resuscitative
Committee and then P & T. The Resuscitative Committee wanted
the box to mimic the box in Interventional Radiology with the
exception of the EpiPen. We developed an algorithm for responding
to contrast reactions (attachment #1) as well as a pocket card
(attachment #2) that the physicians could carry around as a
reference. We were also published in the Journal of American
College of Radiology (JACR) (attachment #3).
This was just the beginning of a process to get the
anaphylactic boxes in use. I had to have the boxes made for us and
order the meds through the Pharmacy. There was a lot of leg work,
back and forth e-mails, training of the physicians and staff and the
implementation of hanging and stocking the boxes. We had to get
posters made and the pocket cards. I also had to create a guideline
for checking and exchanging of the box and the contents along with
a checklist to check the box daily to make sure that the lock had
not been tampered with and the contents had not been
compromised. Medications would have to been exchanged as they
expired so a monthly examination of the box is required. I had
created a guideline for the checking and exchanging of the
emergency boxes, however, Andrew Davis of Pharmacy had
incorporated it into the Policy and Procedure of all the
tackle boxes in the hospital. Our box is officially called Turbo Tackle
Box for Radiology.
I had noticed that when we called a radiologist to a reaction it
took them too long to respond and then asked us what needed to be
done for the patient. Before we were able to hang the boxes we had
to make sure the physicians had been trained in the availability and
use of the boxes. The next step was to provide baseline training for
the residents and fellows to determine their level of comfort and
knowledge in responding to these emergencies. We used simulation
to train the physicians on the emergency box and algorithm for
responding to contrast reactions. We conducted a mock contrast
reaction at the WELLS Center. My role along with Dr. Restauri was
to instruct them on what the scenario was. I was responsible for
recording the mock reaction scenario, being the person on the other
line, when the nurse in the mock scenario called for respiratory, IV
team and code team. I also timed the physicians and recorded how
long it took them to request Epi once they responded. After the
mock contrast reaction training took place, Dr. Restauri, Dr.
Subelong and I would debrief the physicians on what they liked
about the training. We offered feedback on what went right and
what we needed improvement on. After the debriefing, I then was
the one to train them on the use of the EpiPen and record how well
they did at performing administering the EpiPen. I have noticed
that they respond much quicker and that they are much more
knowledgeable and comfortable as evidenced by the way they
communicate with the nurses and the patients.
Since the opening of a satellite clinic with radiology services, I
have had to expand the guideline to this clinic. I have developed an
algorithm that is more conducive to a free standing, radiology clinic
without hospital resources (Attachment #4). They did not want the
emergency boxes on the wall with all of the medications in it. They
only wanted the EpiPen. Some of the physicians have been trained
on the use of the EpiPen and how to respond to contrast reactions. I
have created a power point presentation which includes written and
video instruction on how to use the EpiPen. I am waiting on
approval. Once this is approved it will be rolled out to the other
physicians at the Lone Tree facility. This will be the standard for all
free standing, satellite facilities.
Of course since these boxes have been in place, we have not
had a reaction that has required us to access them. Dr. Restauri
and I will continue to provide training for the physicians and staff
as needed. Our goal is to purchase our own mannequin so that we
can do the training in the AOP. Even though we have not had to
access the emergency boxes, it is very noticeable that the residents
and fellows are quicker to respond and have more confidence. As
you will notice in their evaluations of the training course, they feel
more comfortable and have more confidence in responding to these
types of emergencies.
The monitoring of the effectiveness of these boxes will be an
ongoing project to determine if they will help to save lives. We will
continue to have contrast reactions and the majority are mild to
moderate, however in the case of a patient deteriorating to the point
that a code situation is imminent, I truly believe that these boxes
will be effective in preventing the situation from progressing to that
point.
Please see next two downloads for attachments.