Contrast shed steps guidance

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Technologists and ordering providers can use this list to assess the need for CT IV contrast. Radiologists are available for consultation where necessary.

1) Reduce waste

   a .	For single use vials, try to round down if within 10-25 mls (for example, if 112 ml needed based on weight based dosing, round down and only open 100 ml vial).  For our smallest group of patients, adjust the floor down to 60 ml.  
   b.	Diligently coach patients on breathing instructions before each PE exam to minimize repeat boluses.  Re-bolus only after discussing with radiologist.
   c.	Explore with pharmacy the potential of repackaging large single use containers into either a multiuse container or into smaller single use containers.

2) Minimize Omni/Isovue use for non-IV administration (especially oral contrast).

   a.	If oral contrast is indicated and there is not high concern for perforated bowel, use barium
   b.	If there is high concern for perforated bowel, discuss with radiologist.  Consider no oral contrast or Gastrograffin if oral contrast is absolutely needed.
   c.	Use CystoConray for cystograms

3) No IV contrast for routine chest CT (pulmonary nodules, cancer follow-ups, etc)

4) Use non-contrast CT for indications such as : Abdominal pain (including appendicitis, diverticulitis, etc), hernia, distension. We can always call the patient back for contrast administration if necessary.

5) CT Enterography, replace with MR Enterography where possible.

6) Move known solid organ lesion evaluation to MRI where possible (e.g. renal lesion, adrenal lesion evaluation).

7) Use air instead of contrast for fluoroscopically guided arthrograms. Discuss with radiologist performing the procedure.

8) Neck CT for routine palpable lump – start with non-contrast CT.

9) Stroke CT – Consider non-contrast CT followed by non-contrast brain MRI instead of CTA for appropriate patients. Even if CTA is needed, defer CT perfusion unless very high suspicion- patient can return for perfusion after CTA if needed. At the discretion of the ordering physicians.

10) Move PE scans to MRI during daytime hours or times when there is a tech in house.

11) Consider deferring routine annual follow-up CT scans by 3 months in patients with stable findings on prior exams and no evidence of progression based on tumor markers / clinical factors. Consider deferring CT urograms with low suspicion if ordering clinician allows.

12) For bulk injectors, reduce the amount of contrast administered for all non-perfusion, non-coronary CTA exams by 20%. Adjust rate of injection rather than timing.