Rates of Breakthrough Reactions in Inpatients at High Risk Receiving Premedication Before Contrast-Enhanced CT

Mervak, Benjamin M.; Davenport, Matthew S.; Ellis, James H.; Cohan, Richard H.

doi:10.2214/ajr.14.13810

Cited by 64 publications

(42 citation statements)

References 17 publications

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“…Authors of the second randomized trial (6), which was published in 1994, showed that corticosteroid prophylaxis administered to patients in the general population (n = 1155) before the injection of modern lower-risk lowosmolality iodinated contrast material resulted in a significant reduction in aggregate and grade 1 reactions, but no significant reduction was observed in grade 2 or 3 reactions. Researchers suggested that this inability to demonstrate a reduction in clinically important moderate or severe reactions was related to study size and statistical power, but that argument raises questions about the number needed to treat (NNT) (7,8).…”

Section: Study Cohort: Population Detailsmentioning

confidence: 99%

“…Although corticosteroids do prevent severe allergiclike reactions to low or iso-osmolality iodinated contrast material, the effect has been shown to be incomplete (7,14,15), breakthrough reactions can occur (14,15), and the NNT is large (7). Therefore, we are interested to know whether the costs and indirect harm associated with corticosteroid prophylaxis are greater than the potential benefits.…”

Section: Study Cohort: Population Detailsmentioning

confidence: 99%

“…Seventeen subjects in the control cohort and 19 subjects in the premedicated cohort were younger than 18 years old. One thousand fiftyone subjects in the premedicated cohort had been included in a prior study (7) in which investigators evaluated the NNT with oral 13-hour corticosteroid …”

Section: Study Cohort: Premedicationmentioning

confidence: 99%

“…Table 1 summarizes the input variables and their data sources for this hypothetical cohort analysis (current study and previous studies [7,9,[12][13][16][17]21]). The base case estimate for NNT (ie, n = 69 to prevent a reaction of any severity, n = 569 to prevent a severe reaction) was derived from a large (n = 1051) retrospective analysis (7) in which the NNT with 13-hour premedication to prevent one reaction of varying severity in high-risk subjects undergoing contrast-enhanced CT was investigated. All calculations involving NNT were based on data from a population of patients premedicated for a prior allergic-like reaction (any severity) to iodinated contrast media and not to one or more alternate premedication indications that sometimes are used in the United States (eg, other severe allergies or asthma) (1,7).…”

Section: Health Policy and Practice: Corticosteroid Prophylaxis Beformentioning

confidence: 99%

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Indirect Cost and Harm Attributable to Oral 13-Hour Inpatient Corticosteroid Prophylaxis before Contrast-enhanced CT

Davenport¹,

Mervak²,

Ellis³

et al. 2016

Radiology

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Purpose:To estimate the effect of an oral 13-hour inpatient corticosteroid premedication regimen on length of stay, hospital cost, and hospital-acquired infections (HAIs) by using a combination of real and hypothetical study populations. Materials and Methods:Institutional review board approval was obtained and informed consent waived for this HIPAA-compliant retrospective study. Inpatients who received an oral 13-hour corticosteroid premedication regimen before contrast material-enhanced CT (n = 1424) from 2008 to 2013 were matched by age, sex, and year when CT was performed to a control cohort (n = 1425) of patients who underwent contrast-enhanced CT without premedication and who had similar rates of 13 comorbid diseases. Length of stay in the hospital and time from admission to CT were compared by using the Mann-Whitney U test. Rates of prospectively reported HAIs were compared by using x 2 tests. The indirect cost and risk of HAI with premedication were estimated by using published data. Results:Premedicated inpatients had a significantly longer median length of stay (+25 hours; 158 vs 133 hours, P , .001), a significantly longer median time to CT (+25 hours, 42 vs 17 hours, respectively; P , .001), and a significantly greater risk of HAI (5.1% [72 of 1424] vs 3.1% [44 of 1424], respectively; P = .008) compared with nonpremedicated control subjects. On the basis of these data and existing references, the prolonged length of stay was estimated to result in 0.04 HAI-related deaths and a cost of $159 131 (in U.S. dollars) for each prevented reaction of any severity and 32 HAI-related deaths and a cost of $131 211 400 for each prevented reaction-related death. Conclusion:Oral 13-hour inpatient corticosteroid prophylaxis is associated with substantial cost relative to its modest benefit, and may cause more indirect harm than the direct harm that it prevents.q RSNA, 2015

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Section: Study Cohort: Population Detailsmentioning

confidence: 99%

Section: Study Cohort: Population Detailsmentioning

confidence: 99%

Section: Study Cohort: Premedicationmentioning

confidence: 99%

Section: Health Policy and Practice: Corticosteroid Prophylaxis Beformentioning

confidence: 99%

See 2 more Smart Citations

Indirect Cost and Harm Attributable to Oral 13-Hour Inpatient Corticosteroid Prophylaxis before Contrast-enhanced CT

Davenport¹,

Mervak²,

Ellis³

et al. 2016

Radiology

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“…However, as the efficacy of corticosteroids is not 100%, a limited number of patients will continue to have breakthrough reactions. 8,9) Desensitization has long been used for refractory allergic reactions to common allergens such as bee venom or penicillin. It is defined as the graduated exposure of an allergen to a patient, in order to create a temporary state of tolerance to that agent.…”

Section: )mentioning

confidence: 99%

Rapid Desensitization to Overcome Contrast Allergy Prior to Urgent Coronary Angiography

2018

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SummaryAllergic reactions to contrast media are a frequently reported complication of coronary angiography. The majority of patients experience mild, self-limited episodes, but in rare cases patients may experience severe, persistent symptoms. A strategy of premedication with corticosteroids and anti-histamines and an optimal selection of contrast agent is almost always successful in averting contrast reactions, yet a select few patients will continue to have breakthrough events. This is a case of recurrent, severe allergy to contrast media despite standard precautions complicating the treatment of non-ST elevation myocardial infarction (NSTEMI). Our patient was successfully managed with a strategy of rapid desensitization to iodinated contrast media achieved by administering progressively incremental doses of the media.(Int Heart J Advance Publication) Key words: Coronary artery disease, Chemotoxic reaction, Anaphylactoid reaction M inor allergic reactions to contrast media are a frequently reported complication of coronary angiography though severe allergic reactions are much less common. Such events are typically prevented with premedication and selection of appropriate contrast media prior to the procedure. Here we present a case of refractory, severe allergic reaction to contrast media during coronary angiography that was successfully managed with a desensitization protocol. Case ReportThe patient was a 67-year-old man with a history of non-obstructive coronary artery disease (CAD) diagnosed 3 years previously on a coronary angiogram that demonstrated a 50% stenosis in the mid left anterior descending artery (LAD), pacemaker placement for complete heart block (CHB), asthma and bladder cancer who was initially admitted to our affiliated Veterans Hospital for a planned cystoscopy/retrograde pyelogram. While in recovery in the post-anesthesia care unit he informed his nurse of intra-operative chest pain that had since resolved. An electrocardiogram (ECG) was unchanged from baseline. His first troponin was 0.18. He was started on dual antiplatelet therapy and anticoagulation and continued on his beta-blocker and statin. His troponin peaked at 0.20 the following day. Urgent revascularization for NSTEMI was scheduled for the following morning.Pre-catheterization evaluation revealed a significant history of allergic reaction to contrast media. In early 2013 the patient developed nausea and an erythematous, pruritic rash following a contrast-enhanced CT scan of the abdomen and pelvis. A contrast allergy was added to his medical record. He was scheduled for coronary angiography later that year, and was pretreated with oral prednisone 50 mg (13 hours, 7 hours and 1 hour pre-procedure), as well as oral diphenhydramine (1 hour pre-procedure). Despite pretreatment he developed severe nausea and pruritus, with scattered erythema and bullae noted on exam. He was treated with intravenous methylprednisolone, famotidine, and diphenhydramine, and monitored in the ICU for 2 days. He was hospitalized again in 2014 after develop...

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Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Pain in the Emergency Department

et al. 2023

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ImportanceIntravenous (IV) contrast medium is sometimes withheld due to risk of complication or lack of availability in patients undergoing computed tomography (CT) for abdominal pain. The risk from withholding contrast medium is understudied.ObjectiveTo determine the diagnostic accuracy of unenhanced abdominopelvic CT using contemporaneous contrast-enhanced CT as the reference standard in emergency department (ED) patients with acute abdominal pain.Design, Setting, and ParticipantsThis was an institutional review board–approved, multicenter retrospective diagnostic accuracy study of 201 consecutive adult ED patients who underwent dual-energy contrast-enhanced CT for the evaluation of acute abdominal pain from April 1, 2017, through April 22, 2017. Three blinded radiologists interpreted these scans to establish the reference standard by majority rule. IV and oral contrast media were then digitally subtracted using dual-energy techniques. Six different blinded radiologists from 3 institutions (3 specialist faculty and 3 residents) interpreted the resulting unenhanced CT examinations. Participants included a consecutive sample of ED patients with abdominal pain who underwent dual-energy CT.ExposureContrast-enhanced and virtual unenhanced CT derived from dual-energy CT.Main outcomeDiagnostic accuracy of unenhanced CT for primary (ie, principal cause[s] of pain) and actionable secondary (ie, incidental findings requiring management) diagnoses. The Gwet interrater agreement coefficient was calculated.ResultsThere were 201 included patients (female, 108; male, 93) with a mean age of 50.1 (SD, 20.9) years and mean BMI of 25.5 (SD, 5.4). Overall accuracy of unenhanced CT was 70% (faculty, 68% to 74%; residents, 69% to 70%). Faculty had higher accuracy than residents for primary diagnoses (82% vs 76%; adjusted odds ratio [OR], 1.83; 95% CI, 1.26-2.67; P = .002) but lower accuracy for actionable secondary diagnoses (87% vs 90%; OR, 0.57; 95% CI, 0.35-0.93; P &lt; .001). This was because faculty made fewer false-negative primary diagnoses (38% vs 62%; OR, 0.23; 95% CI, 0.13-0.41; P &lt; .001) but more false-positive actionable secondary diagnoses (63% vs 37%; OR, 2.11, 95% CI, 1.26-3.54; P = .01). False-negative (19%) and false-positive (14%) results were common. Interrater agreement for overall accuracy was moderate (Gwet agreement coefficient, 0.58).ConclusionUnenhanced CT was approximately 30% less accurate than contrast-enhanced CT for evaluating abdominal pain in the ED. This should be balanced with the risk of administering contrast material to patients with risk factors for kidney injury or hypersensitivity reaction.

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Rates of Breakthrough Reactions in Inpatients at High Risk Receiving Premedication Before Contrast-Enhanced CT

Cited by 64 publications

References 17 publications

Indirect Cost and Harm Attributable to Oral 13-Hour Inpatient Corticosteroid Prophylaxis before Contrast-enhanced CT

Indirect Cost and Harm Attributable to Oral 13-Hour Inpatient Corticosteroid Prophylaxis before Contrast-enhanced CT

Rapid Desensitization to Overcome Contrast Allergy Prior to Urgent Coronary Angiography

Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Pain in the Emergency Department

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