Survey of Practicing Radiologists on the Use of Premedication Prior to Intravenous Iodinated Contrast Medium Administration

Purpose: To determine whether updated guidance by the ACR in 2017 advocating use of IV premedication in ED and inpatients with reported iodinated contrast allergy was associated with a change in clinical practice.

Methods/Materials: An anonymous online survey was distributed to practicing radiologist members of the ACR interrogating use of corticosteroid premedication for two clinical vignettes: an indicated routine (within 24 hrs) inpatient contrast-enhanced CT (CE-CT) and an indicated urgent (within 6 hrs) ED CE-CT. In both scenarios, the patient had a prior moderate hypersensitivity reaction to ICM. Clinical management was evaluated. Data were compared to historical data from 2009.

Results: The response rate was 11% (724/6616). For the inpatient scenario, 72% (518/724) would use corticosteroid premedication with CE-CT, and 28% (200/724) would perform noncontrast CT. For the ED scenario, 67% (487/724) would use corticosteroid premedication with CE-CT, and 30% (217/724) would perform noncontrast CT. Oral premedication (85%, 439/518) was preferred for inpatients and rapid IV premedication (89%, 433/487) was preferred for ED patients. For rapid IV dosing in ED, two doses of corticosteroids were used by 50% (216/433) and one dose was used by 43% (185/433), with academic radiologists more likely than private or hybrid practice radiologists to administer two doses (75% vs. 49%, P<.001, OR, 3.1, 95%CI, 1.9-5.2). Rapid IV premedication was more commonly used than in 2009 (60% [433/724] vs. 29% [20/69], P<.001, OR, 3.6, 95%CI, 2.1 – 6.2). Diphenhydramine use was common in both inpatient (91%) and ED (91%) settings. Only 32% of radiologists practiced in accordance with ACR guidelines suggesting no need for routine premedication before CE-CT in patients with prior severe hypersensitivity reaction to gadolinium-based contrast. Most respondents (93%) said the ACR Manual on Contrast Media was a major determinant of their practice.

Conclusions: Use of rapid IV premedication in urgent settings has increased since 2009 following updated ACR guidelines, but there is disagreement over whether 1 or 2 corticosteroid doses is required. Despite reported high reliance on ACR guidelines, deviations from those guidelines remain common.