Radiologic Appropriateness Criteria Sharal Mall, D.O. February 20, 2015

Radiologic Radiologic Appropriateness Appropriateness

CriteriaCriteriaSharal Mall, D.O.Sharal Mall, D.O.

February 20, 2015February 20, 2015

DISCLOSURESDISCLOSURES

NONENONE

Pre-TestPre-Test

1. Pt is a 62 y/o F c/o difficulty swallowing 1. Pt is a 62 y/o F c/o difficulty swallowing (dysphagia).(dysphagia).

20%

20%

20%

20%

20% A.A. Upper GI studyUpper GI study

B.B. Barium Swallow/ Speech EvaluationBarium Swallow/ Speech Evaluation

C.C. EsophagramEsophagram

D.D. CT of the neckCT of the neck

E.E. EGDEGD

What to order next?What to order next?

2. Pt is a 36 y/o M with PMHx of HIV c/o 2. Pt is a 36 y/o M with PMHx of HIV c/o substernal dysphagiasubsternal dysphagia

20%

20%

20%

20%




D.D. CT of the chestCT of the chest

E.E. EGDEGD


3. Pt is a 28 y/o c/o chronic vague abdominal pain 3. Pt is a 28 y/o c/o chronic vague abdominal pain and diarrhea. Crohn’s disease is suspected.and diarrhea. Crohn’s disease is suspected.

20%

20%

20%

20%

20% A.A. UGI with SBFTUGI with SBFT

B.B. CT of the abd/ pelvisCT of the abd/ pelvis

C.C. CT of the abd/ pelvis with IV and PO contrast CT of the abd/ pelvis with IV and PO contrast

D.D. MRI of the abdomenMRI of the abdomen

E.E. Barium enemaBarium enema


4. Pt is a 72 y/o M with PMHx of multiple 4. Pt is a 72 y/o M with PMHx of multiple abdominal surgeries c/o distended stomach abdominal surgeries c/o distended stomach and pain. SBO is suspected.and pain. SBO is suspected.

20%

20%

20%

20%

20% A.A. CT abd/ pelvis without contrastCT abd/ pelvis without contrast

B.B. CT abd/ pelvis with PO contrastCT abd/ pelvis with PO contrast

C.C. CT abd/ pelvis with IV contrastCT abd/ pelvis with IV contrast

D.D. CT abd/ pelvis with PO and IV contrastCT abd/ pelvis with PO and IV contrast

E.E. Abdominal Xray seriesAbdominal Xray series


5. Pt is a 54 y/o F c/o acute chest pain. No EKG 5. Pt is a 54 y/o F c/o acute chest pain. No EKG changes and cardiac enzymes are normal.changes and cardiac enzymes are normal.

20%

20%

20%

20%

20% A.A. CXRCXR

B.B. Chest CT without contrastChest CT without contrast

C.C. Chest CT with contrastChest CT with contrast

D.D. Nuclear Stress Test studyNuclear Stress Test study

E.E. TEETEE


6. Pt is a 67 y/o F with PMHx of EtOH abuse and 6. Pt is a 67 y/o F with PMHx of EtOH abuse and liver cirrhosis. She is c/o hematemesis.liver cirrhosis. She is c/o hematemesis.

20%

20%

20%

20%

20% A.A. CXRCXR

B.B. Invasive angiographyInvasive angiography

C.C. CT abdomenCT abdomen

D.D. EGDEGD

E.E. CT chestCT chest


7. Pt is 32 y/o runner c/o persistent L foot pain. 7. Pt is 32 y/o runner c/o persistent L foot pain. Stress fx is suspected. Initial Xrays are normal.Stress fx is suspected. Initial Xrays are normal.

20%

20%

20%

20%

20% A.A. Repeat XrayRepeat Xray

B.B. CTCT

C.C. MRIMRI

D.D. Bone scanBone scan

E.E. USUS


8. Pt is a 53 y/o F with PMHx DM c/o back pain 8. Pt is a 53 y/o F with PMHx DM c/o back pain and fever. Acute pyelonephritis is suspected.and fever. Acute pyelonephritis is suspected.

20%

20%

20%

20%

20% A.A. USUS

B.B. IVPIVP

C.C. CT abd/ pelvis without contrastCT abd/ pelvis without contrast

D.D. CT abd/ pelvis with IV contrastCT abd/ pelvis with IV contrast

E.E. CT abd/ pelvis with and without IV CT abd/ pelvis with and without IV contrastcontrast


9. Pt is a 53 y/o F c/o painless hematuria. No 9. Pt is a 53 y/o F c/o painless hematuria. No PMHx of renal disease.PMHx of renal disease.

20%

20%

20%

20%

20% A.A. IVPIVP

B.B. CT abd/ pelvis without contrastCT abd/ pelvis without contrast


D.D. MRIMRI

E.E. USUS


10. Pt is 56 y/o M c/o vague Sx. Acute renal 10. Pt is 56 y/o M c/o vague Sx. Acute renal failure is suspected.failure is suspected.

20%

20%

20%

20%

20% A.A. USUS


C.C. CT abd/ pelvis with contrastCT abd/ pelvis with contrast

D.D. MRIMRI

E.E. Nuclear Medicine RenogramNuclear Medicine Renogram


11. Pt is 53 y/o postmenopausal F c/o vague 11. Pt is 53 y/o postmenopausal F c/o vague abdominal pain with suspected adnexal mass abdominal pain with suspected adnexal mass on physical exam. on physical exam.

20%

20%

20%

20%


B.B. CT abd/ pelvis with contrastCT abd/ pelvis with contrast

C.C. USUS

D.D. MRIMRI

E.E. XrayXray


12. Pt is a 65 y/o M c/o acute onset of abdominal 12. Pt is a 65 y/o M c/o acute onset of abdominal pain. PE yields a pulsatile abdominal mass.pain. PE yields a pulsatile abdominal mass.

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20%

20%

20%

20% A.A. Xray KUBXray KUB



D.D. USUS

E.E. colonoscopycolonoscopy


13. 78 y/o M presents with hypotension and rectal 13. 78 y/o M presents with hypotension and rectal bleeding.bleeding.

20%

20%

20%

20%

20% A.A. CT abd/ pelvisCT abd/ pelvis

B.B. CT abd/ pelvis with IV contrastCT abd/ pelvis with IV contrast

C.C. RBC tagged nuclear medicine scanRBC tagged nuclear medicine scan

D.D. ColonoscopyColonoscopy

E.E. Interventional AngiographyInterventional Angiography


14. 64 y/o M c/o sudden onset Lt hand numbness 14. 64 y/o M c/o sudden onset Lt hand numbness and weakness. Acute CVA is suspected. Initial and weakness. Acute CVA is suspected. Initial head CT was ‘nonacute’. head CT was ‘nonacute’.

20%

20%

20%

20%

20% A.A. Lt hand XrayLt hand Xray

B.B. Repeat Head CTRepeat Head CT

C.C. MRI with Gd contrastMRI with Gd contrast

D.D. MRI without contrast MRI without contrast

E.E. USUS


15. An obese 57 y/o F with PMHx DM c/o acute 15. An obese 57 y/o F with PMHx DM c/o acute edematous, painful and erythematous upper edematous, painful and erythematous upper extremity. extremity.

20%

20%

20%

20%

20% A.A. CT with IV contrastCT with IV contrast

B.B. CT without IV contrastCT without IV contrast

C.C. USUS

D.D. XrayXray

E.E. MRIMRI


Plain Film X-Ray / Mammography Plain Film X-Ray / Mammography Cost: Cost: Both plain films and mammography are Both plain films and mammography are

inexpensive inexpensive Risk:Risk: Mortality and morbidity related to exposure to Mortality and morbidity related to exposure to

radiation radiation Availability / AccessAvailability / Access Plain films are widely available Plain films are widely available Mammography is available during business hours Mammography is available during business hours Weight LimitsWeight Limits The IVP table has a limit of 325 pounds. Alternatives to The IVP table has a limit of 325 pounds. Alternatives to

intravenous urography include CT, US, MRI, and intravenous urography include CT, US, MRI, and cystoscopy/retrograde pyelography. cystoscopy/retrograde pyelography.

Plain films have no fixed weight limit, but image quality Plain films have no fixed weight limit, but image quality declines with increasing patient weight and/or size. A declines with increasing patient weight and/or size. A departmental examination is always of better quality than departmental examination is always of better quality than a portable study due to better quality equipment and a portable study due to better quality equipment and higher obtainable radiation parameters. higher obtainable radiation parameters.

Mammography has no specific weight limit. Mammography has no specific weight limit.

UltrasoundUltrasoundCost: Cost: Inexpensive Inexpensive Risk:Risk:Generally non-invasive Generally non-invasive Essentially no mortality or morbidity Essentially no mortality or morbidity Endovaginal, transrectal, transesophageal, Endovaginal, transrectal, transesophageal,

and endocavitary US carry procedural and endocavitary US carry procedural risks related to introduction of the US risks related to introduction of the US probe probe

Availability / Access: Availability / Access: Relatively easily Relatively easily availableavailable

UltrasoundUltrasound

Prep:Prep: Patients should be NPO X 4 hours for GB, liver, Patients should be NPO X 4 hours for GB, liver,

pancreas, and biliary ductal examination pancreas, and biliary ductal examination Weight Limits:Weight Limits: US has no definite fixed weight limit, but image US has no definite fixed weight limit, but image

quality and penetration decline as weight and/or quality and penetration decline as weight and/or size increases size increases

Vascular US has no weight limit per se, but very Vascular US has no weight limit per se, but very large limbs will have poor quality results or not large limbs will have poor quality results or not be able to be meaningfully examined be able to be meaningfully examined

CT (computed tomography)CT (computed tomography)

Cost: Cost: Expensive Expensive Risk:Risk: Mortality and morbidity related to radiation Mortality and morbidity related to radiation

exposure (especially children, breast tissue, exposure (especially children, breast tissue, lens, and ovaries/testes) lens, and ovaries/testes)

Risk related to IV contrast use (death Risk related to IV contrast use (death approximately 1 case per 40,000 – 100,000 approximately 1 case per 40,000 – 100,000 uses) uses)

Oral contrast poses no real risk, except in pts Oral contrast poses no real risk, except in pts who aspirate water soluable contrastwho aspirate water soluable contrast

CTCT Availability / Access: Availability / Access: Relatively easily available Relatively easily available Generally non-invasive Generally non-invasive All patients must be assessed for ability to receive IV All patients must be assessed for ability to receive IV

contrast, even in “non-contrast” situations since changing contrast, even in “non-contrast” situations since changing circumstances may necessitate the use of IV contrast. circumstances may necessitate the use of IV contrast.

All use of All use of IV contrastIV contrast requires IV access; of specific requires IV access; of specific importance is that high-pressure contrast injections require importance is that high-pressure contrast injections require at least an 18-gaugeat least an 18-gauge access with a catheter rated to access with a catheter rated to accept high pressures! accept high pressures!

PICC lines and catheters of 20 gauge or less don’t meet PICC lines and catheters of 20 gauge or less don’t meet these requirements unless specifically specified. This has these requirements unless specifically specified. This has particular importance for PE and other CT angiogram particular importance for PE and other CT angiogram procedures (aorta, renal arteries etc.) and may render procedures (aorta, renal arteries etc.) and may render these CT procedures unable to be performed if suitable IV these CT procedures unable to be performed if suitable IV access isn’t available. access isn’t available.

New PICC lines are available that can accept high-New PICC lines are available that can accept high-pressure injections. “Power PICCs”pressure injections. “Power PICCs”

CTCT Prep:Prep: Ideally patients should be NPO X 4 hours before Ideally patients should be NPO X 4 hours before

administration of IV contrast, in case of contrast-induced administration of IV contrast, in case of contrast-induced vomiting, but this is optional if there is any urgency to the vomiting, but this is optional if there is any urgency to the examination examination

Weight Limits:Weight Limits: Relative weight limit of Relative weight limit of 400 pounds400 pounds Absolute weight limit of 450 poundsAbsolute weight limit of 450 pounds Patients with weight over 300 pounds or with protuberant Patients with weight over 300 pounds or with protuberant

abdomens tend to have degraded image quality abdomens tend to have degraded image quality PE studiesPE studies in particular suffer quality image degradation in particular suffer quality image degradation

as weight increases, thus, a as weight increases, thus, a V/Q scan is a better exam V/Q scan is a better exam in large patients in large patients

MRI (Magnetic Resonance Imaging)MRI (Magnetic Resonance Imaging) Cost: Cost: Very expensive Very expensive Risk: Risk: Carries little mortality or morbidity due to electromagnetic Carries little mortality or morbidity due to electromagnetic

exposure or IV contrast exposure or IV contrast Availability / Access:Availability / Access: Less easily available Less easily available Small gauge IV access for IV contrast use is acceptableSmall gauge IV access for IV contrast use is acceptable Prep:Prep: The patient doesn’t need to be NPO, but must be able to The patient doesn’t need to be NPO, but must be able to

lay still lay still In cases of claustrophobia or a non-cooperative patient, In cases of claustrophobia or a non-cooperative patient,

elective sedation may be required; this is elective sedation may be required; this is arranged and arranged and ordered by the referring healthcare providerordered by the referring healthcare provider

Weight Limits:Weight Limits: The mobile MRI have weight limits of 300 pounds. The mobile MRI have weight limits of 300 pounds. Larger patients may require referral to an open MRILarger patients may require referral to an open MRI

Nuclear MedicineNuclear Medicine Cost: Cost: NM is moderately expensive NM is moderately expensive Risk:Risk: Carries minimal mortality and morbidity from the Carries minimal mortality and morbidity from the

radiation and associated labeled radiopharmaceuticalsradiation and associated labeled radiopharmaceuticals Availability / Access: Availability / Access: less available less available Small gauge IV access for IV radiopharmaceutical use is Small gauge IV access for IV radiopharmaceutical use is

acceptable acceptable PET/CT is considered as a NM procedure and PET/CT is considered as a NM procedure and

scheduled via the nuclear medicine department scheduled via the nuclear medicine department Please note that a Please note that a cooperative patient who isn't cooperative patient who isn't

artificially ventilated is required for the ventilation part of artificially ventilated is required for the ventilation part of a lung V/Q scana lung V/Q scan; if these conditions aren't present, then ; if these conditions aren't present, then an alternative PE examination should be selected an alternative PE examination should be selected

Nuclear MedicineNuclear Medicine Prep:Prep: The patient should be NPO X 4 hours for GB, GB ejection The patient should be NPO X 4 hours for GB, GB ejection

fraction, and cardiac NM examinations fraction, and cardiac NM examinations Cardiac Stress Tests should also require the patient to be Cardiac Stress Tests should also require the patient to be

on a caffeine-free dieton a caffeine-free diet Patients on TPN or whom just ate may have false positive Patients on TPN or whom just ate may have false positive

HIDA scansHIDA scans

Weight Limits:Weight Limits: Single head (camera) nuclear medicine table has a weight Single head (camera) nuclear medicine table has a weight

limit of 300 pounds limit of 300 pounds Dual head NM table has a weight limit of 350 pounds Dual head NM table has a weight limit of 350 pounds PET/CT table has a weight limit of 400-450 pounds PET/CT table has a weight limit of 400-450 pounds There is progressive image degradation as weight There is progressive image degradation as weight

increases due to soft tissue attenuation of the gamma rays increases due to soft tissue attenuation of the gamma rays or positrons being emitted by the radiopharmaceutical.or positrons being emitted by the radiopharmaceutical.

Fluoroscopy (UGI-SBFT-BE) Fluoroscopy (UGI-SBFT-BE) Cost: Cost: moderately expensive moderately expensive Risk:Risk: A procedural risk of perforation (BE) A procedural risk of perforation (BE) Aspiration of oral contrast media (UGI & SBFT) Aspiration of oral contrast media (UGI & SBFT) Potential anaphylaxis due to allergic reaction to the latex balloon Potential anaphylaxis due to allergic reaction to the latex balloon

(BE) (BE) mortality and morbidity related to radiation exposuremortality and morbidity related to radiation exposure

Availability / Access:Availability / Access: Specific informed consent is not required Specific informed consent is not required less available after regular business hoursless available after regular business hours Prep:Prep: Patients scheduled for UGI, SBFT, and BE examinations should be Patients scheduled for UGI, SBFT, and BE examinations should be

on restricted diet and/or bowel prep before their procedures. Details on restricted diet and/or bowel prep before their procedures. Details are available in the radiology department. are available in the radiology department.

Weight LimitsWeight Limits The fluoroscopy table has a weight limit of 350 pounds The fluoroscopy table has a weight limit of 350 pounds Alternatives to fluoroscopy include EGD and Colonoscopy Alternatives to fluoroscopy include EGD and Colonoscopy

Modified Swallow, Esophagram, Modified Swallow, Esophagram, UGI or SBFT?!?!UGI or SBFT?!?!

Modified speech swallowing exam-Modified speech swallowing exam- evaluates swallowing mechanism with evaluates swallowing mechanism with liquid and solid barium preps as well as liquid and solid barium preps as well as tablet formtablet form

EsophagramEsophagram- evaluates esophagus only - evaluates esophagus only and its motilityand its motility

UGIUGI- evaluates esophagus, stomach and - evaluates esophagus, stomach and 11stst and 2 and 2ndnd duodenum; may show reflux duodenum; may show reflux

SBFTSBFT- only evaluates the small bowel (ie, - only evaluates the small bowel (ie, esophagus and stomach are not esophagus and stomach are not evaluated)evaluated)

Biopsy & Angiography / Biopsy & Angiography / Interventional Procedures Interventional Procedures

Angio/interventional procedures are "mini surgeries“!Angio/interventional procedures are "mini surgeries“! Cost:Cost: Biopsy and angio/interventional procedures are expensive Biopsy and angio/interventional procedures are expensive Risk:Risk: Significant procedural risks Significant procedural risks Associated mortality and morbidity from radiation exposure and contrast use Associated mortality and morbidity from radiation exposure and contrast use

(IV, intra-arterial, or intracavitary)(IV, intra-arterial, or intracavitary) Availability / Access:Availability / Access: Availability is by consult to the angio/interventional service. Specific Availability is by consult to the angio/interventional service. Specific

informed consent by the patient or guardian is required in all cases, unless informed consent by the patient or guardian is required in all cases, unless the referring healthcare provider gives emergency consent the referring healthcare provider gives emergency consent

Prep:Prep: There will be formal pre-op and post-op evaluation and monitoring of the There will be formal pre-op and post-op evaluation and monitoring of the

patient to ensure maximum safety during and after the procedure patient to ensure maximum safety during and after the procedure All interventional procedures are usually offered as a “consult” serviceAll interventional procedures are usually offered as a “consult” service Weight Limits:Weight Limits: Vascular US has no weight limit per se, but very large limbs will have poor Vascular US has no weight limit per se, but very large limbs will have poor

quality results or not be able to be meaningfully examinedquality results or not be able to be meaningfully examined

IV Contrast (CT)IV Contrast (CT) CT examinations on patients with a history of severe CT examinations on patients with a history of severe

allergy- e.g. anaphylaxis, throat swelling, difficulty allergy- e.g. anaphylaxis, throat swelling, difficulty breathing related to prior contrast exposure should breathing related to prior contrast exposure should nevernever be performed with IV contrast.be performed with IV contrast.

Informed consent will be obtained by the requesting Informed consent will be obtained by the requesting physician or the radiology technician in the department. physician or the radiology technician in the department.

Prior to contrast administration, the patient or guardian is Prior to contrast administration, the patient or guardian is required to sign an informed consent explicitly stating required to sign an informed consent explicitly stating that the risks, benefits, and alternative choices have that the risks, benefits, and alternative choices have been thoroughly explained to, and understood by the been thoroughly explained to, and understood by the patient or appropriate guardian.patient or appropriate guardian.

All personnel administering contrast are required to All personnel administering contrast are required to confirm the presence of a consent prior to injection.confirm the presence of a consent prior to injection.

IV Contrast (CT)IV Contrast (CT)Immediate Adverse Reactions to CT Contrast Agents:Immediate Adverse Reactions to CT Contrast Agents:

Mild Mild (Incidence, 3%)(Incidence, 3%) Self limited without evidence of progressionSelf limited without evidence of progression

Hives, nasal stuffiness, itching, headache, shaking, dizzinessHives, nasal stuffiness, itching, headache, shaking, dizzinessNot necessarily due to contrast but reported as adverse event: Not necessarily due to contrast but reported as adverse event: Nausea and vomitingNausea and vomiting

Moderate Moderate (Incidence, 0.04%)(Incidence, 0.04%) Clinical findings require treatment and careful observation for Clinical findings require treatment and careful observation for

progressionprogressionTachycardia, bradycardia, hypertension, Tachycardia, bradycardia, hypertension, hypotension, dyspnea, bronchospasm, wheezing, laryngeal hypotension, dyspnea, bronchospasm, wheezing, laryngeal edema, pronounced cutaneous reactionedema, pronounced cutaneous reaction

Severe Severe (Incidence 1-2 per 10,000 injections, 0.01%)(Incidence 1-2 per 10,000 injections, 0.01%) Severe, life threatening symptoms, usually requires Severe, life threatening symptoms, usually requires

hospitalizationhospitalizationLaryngeal edema, convulsions, profound Laryngeal edema, convulsions, profound hypertension, unresponsivenesshypertension, unresponsiveness

Factors that Increase the Risk of Adverse Factors that Increase the Risk of Adverse Reactions to Iodinated Contrast AgentsReactions to Iodinated Contrast Agents

A. A. Systemic ReactionsSystemic Reactions

Previous adverse reactionPrevious adverse reaction

History of asthma or bronchospasmHistory of asthma or bronchospasm

History of allergy or atopyHistory of allergy or atopy

AnxietyAnxiety

Cardiac diseaseCardiac disease

Medication (b-blockers)Medication (b-blockers)

Hematologic and metabolic disease Hematologic and metabolic disease (sickle cell anemia, patients with (sickle cell anemia, patients with thrombotic tendency, multiple thrombotic tendency, multiple myeloma, pheochromocytoma)myeloma, pheochromocytoma)

B. B. Nephrotoxicity/ CINNephrotoxicity/ CIN

Congestive heart failure (New York Congestive heart failure (New York Heart Association class 3 & 4)Heart Association class 3 & 4)

DehydrationDehydration

Renal disease, especially in Renal disease, especially in diabetics treated with metformin diabetics treated with metformin (Glucophage)(Glucophage)

Medications (aspirin, NSAIDs)Medications (aspirin, NSAIDs)

Contrast agents play an important and Contrast agents play an important and sometimes essential role in many kinds of sometimes essential role in many kinds of imaging.imaging.

Clinicians are given the option of Clinicians are given the option of specifying whether contrast is to be used specifying whether contrast is to be used at the time of scheduling. However, if at the time of scheduling. However, if nothing is specified, the radiologist may nothing is specified, the radiologist may make the decision at the time the make the decision at the time the examination is reviewed. examination is reviewed.

Most pediatric radiology studies are Most pediatric radiology studies are protocoled by the radiologist.protocoled by the radiologist.

Indications for IV Contrast in Indications for IV Contrast in Computed TomographyComputed Tomography

History suggests History suggests infectioninfection or abscess (head, abdomen, soft or abscess (head, abdomen, soft tissue)tissue)

Evaluation of suspected inflammatory processEvaluation of suspected inflammatory process Suspected bowel infarct and/ or ischemiaSuspected bowel infarct and/ or ischemia History of History of malignancymalignancy or previous intracranial tumor or previous intracranial tumor Evaluation of metastatic diseaseEvaluation of metastatic disease Evaluation of Evaluation of solid organssolid organs (liver, kidney, spleen) esp. trauma! (liver, kidney, spleen) esp. trauma! Evaluation of Evaluation of vascular pathologyvascular pathology (embolus, dissection, (embolus, dissection,

thrombus, aneurysm, AVM)thrombus, aneurysm, AVM) Proper evaluation of spinal canal in CTProper evaluation of spinal canal in CT CT of the neck (for better distinction of adenopathy)CT of the neck (for better distinction of adenopathy) CT of the mediastinum (better distinction of adenopathy)CT of the mediastinum (better distinction of adenopathy) Proper evaluation of post-transplant patientsProper evaluation of post-transplant patients Soft tissue mass or tumorSoft tissue mass or tumor

Absolute Indications for IV Absolute Indications for IV contrastcontrast

1.1. infection/ abscess/ inflammationinfection/ abscess/ inflammation

2.2. Metastatic disease/ history of cancerMetastatic disease/ history of cancer

3.3. Vascular pathologyVascular pathology

4.4. Suspected solid organ injurySuspected solid organ injury

IV Contrast (CT) ScreeningIV Contrast (CT) Screening Risk of contrast related ARF/ CIN (contrast induced Risk of contrast related ARF/ CIN (contrast induced

nephropathy) is similar for LOCM and HOCM in normal nephropathy) is similar for LOCM and HOCM in normal patients.patients.

Normal patients are classified as those patients with Cr < Normal patients are classified as those patients with Cr < 1.4 mg/dl or well hydrated patients who are moderately 1.4 mg/dl or well hydrated patients who are moderately impaired (Cr < 2 mg/dl) with or without diabetes, and impaired (Cr < 2 mg/dl) with or without diabetes, and may be injected. may be injected.

Patients undergoing hemodialysis should be scheduled Patients undergoing hemodialysis should be scheduled for dialysis within 6 hours of the contrast injection.for dialysis within 6 hours of the contrast injection.

Diabetics who are on glucophage (Metformin) should be Diabetics who are on glucophage (Metformin) should be instructed to hold the medication for 48 hours following instructed to hold the medication for 48 hours following the CT, pending lab work. the CT, pending lab work.

It is recommended that metformin be withheld for 24 It is recommended that metformin be withheld for 24 hours before the test, however, recent data has shown hours before the test, however, recent data has shown that this is not a contraindication to IV contrast in that this is not a contraindication to IV contrast in emergency situations.emergency situations.

IV Contrast (CT) ScreeningIV Contrast (CT) Screening In patients with known renal disease, DM, In patients with known renal disease, DM,

multiple myeloma, one kidney, renal transplant, multiple myeloma, one kidney, renal transplant, currently undergoing chemotx, gout, prior currently undergoing chemotx, gout, prior abnormal BUN or Cr, advanced heart failure or abnormal BUN or Cr, advanced heart failure or hypovolemia the GFR will be calculated.hypovolemia the GFR will be calculated.

For patients who are on hemodialysis (GFR For patients who are on hemodialysis (GFR <30), dialysis is scheduled at the discretion of <30), dialysis is scheduled at the discretion of the nephrologist or ordering physician. The GFR the nephrologist or ordering physician. The GFR is not calculated. is not calculated.

In patients with GFR <30 mL/min IV contrast is In patients with GFR <30 mL/min IV contrast is contraindicated unless on hemodialysis.contraindicated unless on hemodialysis.

For patients with GFR 30-50 mL/min, hydration For patients with GFR 30-50 mL/min, hydration protocol is performed.protocol is performed.

Patients with GFR 50-60 are instructed to self Patients with GFR 50-60 are instructed to self hydrate before and after the scan.hydrate before and after the scan.

IV Contrast (CT) Prophylaxis IV Contrast (CT) Prophylaxis ProtocolProtocol

For patients with GFR 30-60, hydration protocol of 500 For patients with GFR 30-60, hydration protocol of 500 cc normal saline is given intravenously.cc normal saline is given intravenously.

Mucomyst is not indicated and has never been proven to Mucomyst is not indicated and has never been proven to prevent CIN.prevent CIN.

For patients with a history of moderate or mild contrast For patients with a history of moderate or mild contrast reaction, premedication with Medrol is advised. (32 mg reaction, premedication with Medrol is advised. (32 mg PO x 2, 12 hours and 2 hours before contrast PO x 2, 12 hours and 2 hours before contrast administration) Alternatively, 200 mg of IV administration) Alternatively, 200 mg of IV hydrocortisone can be used for NPO patients. If the hydrocortisone can be used for NPO patients. If the patient is already on daily corticosteroids, prophylaxis is patient is already on daily corticosteroids, prophylaxis is not needed.not needed.

For patients with gout, multiple myeloma, one kidney, For patients with gout, multiple myeloma, one kidney, renal transplant or currently undergoing chemotx renal transplant or currently undergoing chemotx hydration protocol with 250 cc normal saline is given.hydration protocol with 250 cc normal saline is given.

The Iodine Myth: history of allergy to seafood/shellfish The Iodine Myth: history of allergy to seafood/shellfish or topical iodine does not predispose to a contrast or topical iodine does not predispose to a contrast reaction and prophlaxis is not advised.reaction and prophlaxis is not advised.

MRI contrast: GadoliniumMRI contrast: Gadolinium The only real indication for the use of Gd The only real indication for the use of Gd

contrast is in the evaluation of metastasis, contrast is in the evaluation of metastasis, tumors or soft tissue mass lesions.tumors or soft tissue mass lesions.

Gd is also useful in evaluation of vascular Gd is also useful in evaluation of vascular pathology, although special MR techniques pathology, although special MR techniques such as MRV or MRA do not require contrast.such as MRV or MRA do not require contrast.

Gd arthrogram procedures are required to Gd arthrogram procedures are required to adequately evaluate the shoulder labrum, adequately evaluate the shoulder labrum, TFCC of the wrist and labrum of the hip. TFCC of the wrist and labrum of the hip.

Overall incidence of acute reactions is 1 in Overall incidence of acute reactions is 1 in 100,000 (0.01%) for normal patients and 1 in 100,000 (0.01%) for normal patients and 1 in 10,000 for patients with GFR <30.10,000 for patients with GFR <30.

No adverse reactions have ever been reported No adverse reactions have ever been reported with intraarticular Gd contrast.with intraarticular Gd contrast.

Nephrogenic Systemic FibrosisNephrogenic Systemic Fibrosis NSF is a debilitating acquired systemic disorder NSF is a debilitating acquired systemic disorder

characterized by prominent skin manifestations characterized by prominent skin manifestations (fibrosis), which typically spare the face, but also (fibrosis), which typically spare the face, but also affects the lungs, esophagus, heart and skeletal affects the lungs, esophagus, heart and skeletal muscles.muscles.

The etiology of NSF remains unclear, but occurs The etiology of NSF remains unclear, but occurs exclusively in patients with chronic renal failure, and exclusively in patients with chronic renal failure, and the incidence increases with repeated Gd exposure the incidence increases with repeated Gd exposure or higher doses.or higher doses.

Skin lesions typically appear 1 week to 6 months Skin lesions typically appear 1 week to 6 months after contrast exposure.after contrast exposure.

There is no treatment for NSF, and immediate There is no treatment for NSF, and immediate dialysis after Gd adminsitration shows no definite dialysis after Gd adminsitration shows no definite decrease in risk. Plasmaphoresis has been used decrease in risk. Plasmaphoresis has been used with some success.with some success.

Nephrogenic Systemic FibrosisNephrogenic Systemic Fibrosis NSF shows diffuse increased muscle uptake on bone NSF shows diffuse increased muscle uptake on bone

scan, and an edematous increased T2 signal within the scan, and an edematous increased T2 signal within the skin, muscles and fascia on MR.skin, muscles and fascia on MR.

Confirmation is typically made by skin biopsy.Confirmation is typically made by skin biopsy. By 2010, approximately 600 cases have been reported By 2010, approximately 600 cases have been reported

up to that date. (out of 41 million doses)up to that date. (out of 41 million doses) Most reported cases were associated with Most reported cases were associated with

gadodiamide (Omniscan). Conemaugh Health System gadodiamide (Omniscan). Conemaugh Health System uses Optimark. (Multihance is used if the patient has a uses Optimark. (Multihance is used if the patient has a low GFR.)low GFR.)

All patients are now screened before receiving Gd, and All patients are now screened before receiving Gd, and their GFR is calculated.their GFR is calculated.

Patients who have stage 3, 4 or 5 (end stage) renal Patients who have stage 3, 4 or 5 (end stage) renal disease should not receive Gd contrast.disease should not receive Gd contrast.

Nephrogenic Systemic FibrosisNephrogenic Systemic Fibrosis No consistently effective therapy exists to treat No consistently effective therapy exists to treat

NSF.NSF. The CDC has so far failed to identify a single The CDC has so far failed to identify a single

causative medication, but almost all cases have causative medication, but almost all cases have been reported in patients with GFR < 30 mL/min.been reported in patients with GFR < 30 mL/min.

For patients on hemodialysis, this should be For patients on hemodialysis, this should be performed ideally within 3-4 hours of receiving performed ideally within 3-4 hours of receiving Gd contrast.Gd contrast.

In 2008-2009, virtually no new cases of NSF In 2008-2009, virtually no new cases of NSF were reported after screening protocols were were reported after screening protocols were implemented, even after heightened awareness implemented, even after heightened awareness by the medical community.by the medical community.

No other risk factors have been linked to the No other risk factors have been linked to the development of NSF.development of NSF.

Where’s the appendix?!?Where’s the appendix?!?

There it is!There it is!

Barium vs. H2O solubleBarium vs. H2O soluble enteric contrast enteric contrast

Patients who are at risk for aspiration should not Patients who are at risk for aspiration should not receive H2O soluble contrast. If aspirated, this receive H2O soluble contrast. If aspirated, this can cause severe pulmonary edema or chemical can cause severe pulmonary edema or chemical pneumonitis.pneumonitis.

Patients with suspected bowel perforation Patients with suspected bowel perforation should receive water or H2O soluble enteric should receive water or H2O soluble enteric contrast. Barium can cause chemical peritonitis contrast. Barium can cause chemical peritonitis and is not absorbed. No allergic reactions have and is not absorbed. No allergic reactions have ever been reported from barium contrast.ever been reported from barium contrast.

H2O soluble contrast agents can be used for H2O soluble contrast agents can be used for therapeutic enemas.therapeutic enemas.

Breast Feeding or Pregnancy Breast Feeding or Pregnancy Contrast IssuesContrast Issues

Pregnant women should not receive IV contrast Pregnant women should not receive IV contrast of any kind, including nuclear isotopes. of any kind, including nuclear isotopes. Iodinated contrast is harmful to the developing Iodinated contrast is harmful to the developing fetal thyroid and nuclear isotopes expose the fetal thyroid and nuclear isotopes expose the fetus to systemic radiation. Enteric contrast is fetus to systemic radiation. Enteric contrast is safe for any study, although the radiation risk of safe for any study, although the radiation risk of xray or CT exams is unknown.xray or CT exams is unknown.

Breast feeding mothers can receive IV contrast, Breast feeding mothers can receive IV contrast, Gd contrast or nuclear medicine studies. Oral Gd contrast or nuclear medicine studies. Oral fluids should be encouraged. fluids should be encouraged.

ACR Appropriateness CriteriaACR Appropriateness Criteria

The ACR Appropriateness Criteria® are The ACR Appropriateness Criteria® are evidence-based guidelines to assist evidence-based guidelines to assist referring physicians and other providers in referring physicians and other providers in making the most appropriate imaging or making the most appropriate imaging or treatment decision. By employing these treatment decision. By employing these guidelines, providers enhance quality of guidelines, providers enhance quality of care and contribute to the care and contribute to the most efficacious most efficacious use of radiology.use of radiology.

A mobile version of the ACR Appropriateness Criteria® A mobile version of the ACR Appropriateness Criteria® found on the ACR's Web site, the found on the ACR's Web site, the Anytime, Anywhere Anytime, Anywhere ApplicationApplication. .

This application gives instant, point-of-care access to This application gives instant, point-of-care access to the most recent evidence-based clinical practice the most recent evidence-based clinical practice guidelines for imaging decisions for diagnostic imaging, guidelines for imaging decisions for diagnostic imaging, interventional radiology and radiation oncology based interventional radiology and radiation oncology based on expert consensus and also includes relative radiation on expert consensus and also includes relative radiation level exposures and summaries from literature reviews. level exposures and summaries from literature reviews.

It contains more than 175 topics with over 850 additional It contains more than 175 topics with over 850 additional variants and includes topics from the following expert variants and includes topics from the following expert panels: cardiovascular, gastrointestinal, panels: cardiovascular, gastrointestinal, musculoskeletal, neurologic, thoracic, urologic, musculoskeletal, neurologic, thoracic, urologic, pediatric, women's imaging, interventional radiology, pediatric, women's imaging, interventional radiology, and radiation oncology. and radiation oncology.

www.acr.org/ac Anytime, Anywhere Application is available Anytime, Anywhere Application is available

for most mobile devices, including the for most mobile devices, including the iPhone, iPad, BlackBerry, Palm, PDA or other iPhone, iPad, BlackBerry, Palm, PDA or other smart phones.smart phones.

Searchable by topic or procedure. Searchable by topic or procedure.

Example of Topics:Example of Topics:

Expert Panel on Cardiovascular ImagingExpert Panel on Cardiovascular Imaging CardiacCardiac • • Acute Chest Pain—No ECG or Enzyme Evidence of Myocardial Acute Chest Pain—No ECG or Enzyme Evidence of Myocardial

Ischemia/InfarctionIschemia/Infarction • • Acute Chest Pain—Suspected Aortic DissectionAcute Chest Pain—Suspected Aortic Dissection • • Acute Chest Pain—Suspected Myocardial IschemiaAcute Chest Pain—Suspected Myocardial Ischemia • • Acute Chest Pain—Suspected Pulmonary EmbolismAcute Chest Pain—Suspected Pulmonary Embolism • • Chronic Chest Pain—No Evidence of Myocardial Ischemia/Infarction Chronic Chest Pain—No Evidence of Myocardial Ischemia/Infarction

(Update in Progress)(Update in Progress) • • Chronic Chest Pain—Suspected Cardiac OriginChronic Chest Pain—Suspected Cardiac Origin • • Congestive Heart FailureCongestive Heart Failure • • Shortness of Breath—Suspected Cardiac OriginShortness of Breath—Suspected Cardiac Origin • • Suspected Bacterial EndocarditisSuspected Bacterial Endocarditis • • Suspected Congenital Heart Disease in the AdultSuspected Congenital Heart Disease in the Adult

Post- TestPost- Test

1. Pt is a 62 y/o F c/o difficulty swallowing 1. Pt is a 62 y/o F c/o difficulty swallowing (dysphagia).(dysphagia).

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20%




D.D. CT of the neckCT of the neck

E.E. EGDEGD

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10

1. Pt is a 62 y/o F c/o difficulty swallowing (dysphagia).

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20%

20%

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Upper GI study

Barium Swallow/ SpeechEvaluation

Esophagram

CT of the neck

EGD

First Slide Second Slide

2. Pt is a 36 y/o M with PMHx of HIV c/o 2. Pt is a 36 y/o M with PMHx of HIV c/o substernal dysphagiasubsternal dysphagia

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20%




D.D. CT of the chestCT of the chest

E.E. EGDEGD

CountdownCountdown

10

2. Pt is a 36 y/o M with PMHx of HIV c/o substernal dysphagia

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Upper GI study

Barium Swallow/ SpeechEvaluation

Esophagram

CT of the chest

EGD


3. Pt is a 28 y/o c/o chronic vague 3. Pt is a 28 y/o c/o chronic vague abdominal pain and diarrhea. Crohn’s abdominal pain and diarrhea. Crohn’s disease is suspected.disease is suspected.

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20%

20%

20%

20% A.A. UGI with SBFTUGI with SBFT

B.B. CT of the abd/ pelvisCT of the abd/ pelvis

C.C. CT of the abd/ pelvis with IV and PO contrast CT of the abd/ pelvis with IV and PO contrast

D.D. MRI of the abdomenMRI of the abdomen

E.E. Barium enemaBarium enema

CountdownCountdown

10

3. Pt is a 28 y/o c/o chronic vague abdominal pain and diarrhea. Crohn’s disease is suspected.

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20%

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UGI with SBFT

CT of the abd/ pelvis

CT of the abd/ pelvis with IVand PO contrast

MRI of the abdomen

Barium enema


4. Pt is a 72 y/o M with PMHx of multiple 4. Pt is a 72 y/o M with PMHx of multiple abdominal surgeries c/o distended abdominal surgeries c/o distended stomach and pain. SBO is suspected.stomach and pain. SBO is suspected.

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20%


B.B. CT abd/ pelvis with PO contrastCT abd/ pelvis with PO contrast


D.D. CT abd/ pelvis with PO and IV contrastCT abd/ pelvis with PO and IV contrast

E.E. Abdominal Xray seriesAbdominal Xray series

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4. Pt is a 72 y/o M with PMHx of multiple abdominal surgeries c/o distended stomach and pain. SB...

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CT abd/ pelvis withoutcontrast

CT abd/ pelvis with POcontrast

CT abd/ pelvis with IVcontrast

CT abd/ pelvis with PO andIV contrast

Abdominal Xray series


5. Pt is a 54 y/o F c/o acute chest pain. No 5. Pt is a 54 y/o F c/o acute chest pain. No EKG changes and cardiac enzymes are EKG changes and cardiac enzymes are normal.normal.

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20%

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20% A.A. CXRCXR

B.B. Chest CT without contrastChest CT without contrast

C.C. Chest CT with contrastChest CT with contrast

D.D. Nuclear Stress Test studyNuclear Stress Test study

E.E. TEETEE

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10

5. Pt is a 54 y/o F c/o acute chest pain. No EKG changes and cardiac enzymes are normal.

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CXR

Chest CT without contrast

Chest CT with contrast

Nuclear Stress Test study

TEE


6. Pt is a 67 y/o F with PMHx of EtOH abuse 6. Pt is a 67 y/o F with PMHx of EtOH abuse and liver cirrhosis. She is c/o and liver cirrhosis. She is c/o hematemesis.hematemesis.

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20% A.A. CXRCXR

B.B. Invasive angiographyInvasive angiography

C.C. CT abdomenCT abdomen

D.D. EGDEGD

E.E. CT chestCT chest

CountdownCountdown

10

6. Pt is a 67 y/o F with PMHx of EtOH abuse and liver cirrhosis. She is c/o hematemesis.

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CXR

Invasive angiography

CT abdomen

EGD

CT chest


7. Pt is 32 y/o runner c/o persistent L foot 7. Pt is 32 y/o runner c/o persistent L foot pain. Stress fx suspected. Initial Xrays pain. Stress fx suspected. Initial Xrays are normal.are normal.

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20% A.A. Repeat XrayRepeat Xray

B.B. CTCT

C.C. MRIMRI

D.D. Bone scanBone scan

E.E. USUS

CountdownCountdown

10

7. Pt is 32 y/o runner c/o persistent L foot pain. Stress fx suspected. Initial Xrays are normal.

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Repeat Xray

CT

MRI

Bone scan

US


8. Pt is a 53 y/o F with PMHx DM c/o back 8. Pt is a 53 y/o F with PMHx DM c/o back pain and fever. Acute pyelonephritis is pain and fever. Acute pyelonephritis is suspected.suspected.

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20%

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20% A.A. USUS

B.B. IVPIVP

C.C. CT abd/ pelvis without contrastCT abd/ pelvis without contrast

D.D. CT abd/ pelvis with IV contrastCT abd/ pelvis with IV contrast

E.E. CT abd/ pelvis with and without IV CT abd/ pelvis with and without IV contrastcontrast

CountdownCountdown

10

8. Pt is a 53 y/o F with PMHx DM c/o back pain and fever. Acute pyelonephritis is suspected.

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US

IVP



CT abd/ pelvis with andwithout IV contrast


9. Pt is a 53 y/o F c/o painless hematuria. 9. Pt is a 53 y/o F c/o painless hematuria. No PMHx of renal disease.No PMHx of renal disease.

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20% A.A. IVPIVP



D.D. MRIMRI

E.E. USUS

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10

9. Pt is a 53 y/o F c/o painless hematuria. No PMHx of renal disease.

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IVP



MRI

US


10. Pt is 56 y/o M c/o vague Sx. Acute renal 10. Pt is 56 y/o M c/o vague Sx. Acute renal failure is suspected.failure is suspected.

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D.D. MRIMRI

E.E. Nuclear Medicine RenogramNuclear Medicine Renogram

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10. Pt is 56 y/o M c/o vague Sx. Acute renal failure is suspected.

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US


CT abd/ pelvis with contrast

MRI

Nuclear Medicine Renogram


11. Pt is 53 y/o postmenopausal F c/o vague 11. Pt is 53 y/o postmenopausal F c/o vague abdominal pain with suspected adnexal abdominal pain with suspected adnexal mass on physical exam. mass on physical exam.

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B.B. CT abd/ pelvis with contrastCT abd/ pelvis with contrast

C.C. USUS

D.D. MRIMRI

E.E. XrayXray

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10

11. Pt is 53 y/o postmenopausal F c/o vague abdominal pain with suspected adnexal mass on physica...

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US

MRI

Xray


12. Pt is a 65 y/o M c/o acute onset of 12. Pt is a 65 y/o M c/o acute onset of abdominal pain. PE yields a pulsatile abdominal pain. PE yields a pulsatile abdominal mass.abdominal mass.

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20% A.A. Xray KUBXray KUB



D.D. USUS

E.E. colonoscopycolonoscopy

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10

12. Pt is a 65 y/o M c/o acute onset of abdominal pain. PE yields a pulsatile abdominal mass.

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Xray KUB



US

colonoscopy


13. 78 y/o M presents with hypotension and 13. 78 y/o M presents with hypotension and rectal bleeding.rectal bleeding.

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20% A.A. CT abd/ pelvisCT abd/ pelvis

B.B. CT abd/ pelvis with IV contrastCT abd/ pelvis with IV contrast

C.C. RBC tagged nuclear medicine scanRBC tagged nuclear medicine scan

D.D. ColonoscopyColonoscopy

E.E. Interventional AngiographyInterventional Angiography

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10

13. 78 y/o M presents with hypotension and rectal bleeding.

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CT abd/ pelvis


RBC tagged nuclearmedicine scan

Colonoscopy

Interventional Angiography


14. 64 y/o M c/o sudden onset Lt hand 14. 64 y/o M c/o sudden onset Lt hand numbness and weakness. Acute CVA is numbness and weakness. Acute CVA is suspected. Initial head CT was suspected. Initial head CT was ‘nonacute’. ‘nonacute’.

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20% A.A. Lt hand XrayLt hand Xray

B.B. Repeat Head CTRepeat Head CT

C.C. MRI with Gd contrastMRI with Gd contrast

D.D. MRI without contrast MRI without contrast

E.E. USUS

CountdownCountdown

10

14. 64 y/o M c/o sudden onset Lt hand numbness and weakness. Acute CVA is suspected. Initial hea...

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Lt hand Xray

Repeat Head CT

MRI with Gd contrast

MRI without contrast

US


15. An obese 57 y/o F with PMHx DM c/o 15. An obese 57 y/o F with PMHx DM c/o acute edematous, painful and acute edematous, painful and erythematous upper extremity. erythematous upper extremity.

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20% A.A. CT with IV contrastCT with IV contrast

B.B. CT without IV contrastCT without IV contrast

C.C. USUS

D.D. XrayXray

E.E. MRIMRI

CountdownCountdown

10

15. An obese 57 y/o F with PMHx DM c/o acute edematous, painful and erythematous upper extremity.

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CT with IV contrast

CT without IV contrast

US

Xray

MRI


www.acr.orgwww.acr.org

ResourcesResources

www.radiology.mcg.edu/RadPrimerwww.acr.orghttp://resweb.med.nyu.edu/imageswww.mghradrounds.orgwww.uphs.upenn.edu/radiologyACR Manual on Contrast Media, version ACR Manual on Contrast Media, version

7. 20107. 2010

Documents

Radiologic Appropriateness Criteria Sharal Mall, D.O. February 20, 2015