J Am Coll Radiol. 2023 Jul 27:S1546-1440(23)00532-X. doi: 10.1016/j.jacr.2023.04.024. Online ahead of print.
OBJECTIVE: To determine whether updated guidance by the American College of Radiology (ACR) in 2017 advocating use of IV premedication in ED patients and inpatients with reported iodinated contrast allergy was associated with a change in clinical practice.
METHODS: An anonymous survey was distributed via e-mail in October 2020 to practicing radiologist members of the ACR interrogating use of corticosteroid premedication for two clinical vignettes: an indicated routine (perform within 24 hours) inpatient contrast enhanced CT (CE-CT) and an indicated urgent (perform within 6 hours) 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 controls 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 routine inpatients and rapid IV premedication (89%, 433/487) was preferred for urgent ED patients. Of those that provided rapid IV dosing data in the ED, two doses of corticosteroids were used by 53% (216/410) and one dose was used by 45% (185/410), with academic radiologists more likely than private or hybrid practice radiologists to administer two doses (74% [74/100] versus 48% [151/312], P < .001, odds ratio, 3.03, 95% CI, 1.84-5.00). Rapid IV premedication was more commonly used in 2020 than in 2009 (60% [433/724] vs. 29% [20/69], P < .001, OR, 3.65, 95% CI, 2.12 - 6.26). Antihistamine use was common in both inpatient (93%, 480/518) and ED settings (92%, 447/487). Only 32% [229/721] of radiologist's 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 media. Nonetheless, most (93%, 670/724) 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 one or two corticosteroid doses is required. Despite reported high reliance on ACR guidelines, deviations from those guidelines remain common. In general, when ACR guidelines were not followed, it was in a risk-averse direction.