CT Examinations in Adults: Use of Central Venous Catheters (CVC) and Peripherally Inserted Central Catheters (PICC) for Injection of Contrast (673)

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Situation

On occasion there may be the need to consider injection of iodinated contrast via a central venous catheter (CVC) or peripherally inserted central catheter (PICC) for a CT examination in the adult population. Concerns have been raised about the safety of this practice.

This guideline is intended for use by:
• Radiographers and radiographic staff within the Diagnostics Directorate,
• ITU medical staff and Advanced Critical Care Practitioners

Background

The injection of contrast is a fundamental component of many CT examinations, often requiring large volumes at high flow rates. This is generally achieved via a peripheral venous catheter (PVC), however in some patients the only venous access is through a central venous catheter (CVC) or peripherally inserted central catheter (PICC).

Some catheters are designed for use with the high pressures generated by pump injectors, and are marked as such. For standard CVCs and PICCs, however, there are no published UK recommendations for their use for this indication. The Medicines and Healthcare Products Regulatory Agency (MHRA) issued a device alert suggesting injection at a maximum rate of 2ml/s and a pressure limit below the manufacturer’s recommended maximum.

Assessment

The use of CVCs for pump injections has been variable across radiology departments within NHSGGC. Anecdotally pump contrast injections via CVCs have been performed on a case by case basis with no locally reported significant complications. Complication rates within the published literature are also difficult to establish but one paper sites a crude event rate of 0.7%. This does however suggest that it may that the potential risk from injection via a standard CVC is outweighed by the need to perform the study with contrast.

Recommendation

1. Firstly, determine if the available line is CT compatible. Refer to the poster displayed in control rooms, and available on Q-Pulse, Guidance for Pressure Injection in CT, DR-GGC-GUID-016 for help identifying if the line is compatible - Appendix 1.


2. If it is not, refer to the second poster, displayed in control rooms, and available on Q-Pulse, Emergency Use of Standard CVCs with CT Power Injection, DR-GGC-GUID-017. This flowchart allows you to make decisions on a case by case basis – Appendix 2, based on Plumb et al (2011).

References

1. Medicines and Healthcare products Regulatory Agency. Medical Device Alert MDA/204/010. Issued 25 Feb 2004


2. Plumb AAO, Murphy G. The use of central venous catheters for intravenous contrast injection for CT examinations. (2011) The British Journal of Radiology, 84, 197 – 203

Appendix 1: Guidance for Pressure Injection in CT, DR-GGC-GUID-016

Appendix 2: Emergency Use of Standard CVCs with CT Power Injection, DR-GGC-GUID-017

Last reviewed: 19 May 2021

Next review: 21 May 2023

Author(s): Dr Ross MacDuff / Dr Andrew Downie

Version: 2

Author Email(s): [email protected]

Approved By: Diagnostics Clinical Governance Group

Document Id: 673