[DutchgirlRN]

We are instituting a protocol for hydration prior to iodinated contrast medium. Here's what it says:

An order initiating this protocol was written in the medical record by the prescribing practioner. (this sounds awkward?)

Lab for GFR calculation. Serum creatinine and BUN.

Obtain serum creatinine and calculate GFR 48 hours before contrast medium

Hold metformin until GFR is greater than 40ml and for 48 hours after exposure of the patient to contrast medium

All patients with GFR 30-60 ml/min

IV Fluid Bolus: 0.45% Sodium Chloride plus Sodium Bicarbonate 50mEq per liter
250 ml bolus before and after administration of contrast medium
Mucomyst 600 mg PO x 1 dose before contrast medium and Mucomyst 600mg PO every 12 hour x2 after the exam z(this is worded awkwardly)

Pt's with a GFR less than 30ml/min

Nephrology evaluation prior to imaging or consideralternate imaging approaches if any risk factors present

Dialysis Patients:
No hydration necessary, continue with exam (isn't it only if dialysis is scheduled for the patient within so many hours of the exam.

How to we figure in CHF patients who are on fluid restrictions? Those with COPD? Wheezing?

Any suggestions to make this protocol clearer and more concise? Thanks !!!!!

[Diary/Dairy]

Yes - that is a little bit difficult to understand.....

[agent66]

We have started something similar, calculating the Creatinine clearance, and holding metformin for 48hours post procedure. It is still doc dependant if they want the hydration orders or not with the bicarb infusions. Some just still go for the mucomyst , some want the mucomyst and hydration. Why must protocols be so difficult? The docs don't check it , they think is standard, but actually they have to check it off IF they want it, oh boy so much confusion. You would think also they could calculate the number themselves on their order sheet and do the orders right away if the number warrants it. But they leave it for nursing to do and call them back later . Oh and did i mention often the CRCL is not even calculated , but found in the middle of the night, pre procedure? That gets a 7am call to the doc in his car who doesn't even know the patient. Great system.

[dianah]

The prescribing practitioner is responsible for writing orders initiating pre-exam hydration protocol, to include (but not limited to) the following:
1. Serum BUN and creatinine drawn [within one month of iodine contrast-enhanced exam].
2. Imaging Staff to calculate eGFR 48 hours before exam.
If eGFR between 30-60ml/min:
*IV fluid: 0.45% NaCl with NaHCO3- 50mEq/Liter, 250ml bolus before and 250ml after contrast administration [probably need a rate here, e.g., 999ml/hr X 250ml].
*Mucomyst 600mg PO X 3 (total 1800 mg): One dose before contrast administration, one dose 12 hours and one dose 24 hours post-contrast administration.
If eGFR <30ml/min:
*Nephrology evaluation prior to imaging
*Consider alternative non-iodinated contrast imaging

3. Hold Metformin day of exam and for 48 hours after contrast administration.
4. If eGFR <40ml/min, hold Metformin until it is >40ml, and then for 48 hours post-contrast administration.
5. Dialysis patients: No pre-exam hydration necessary. [check w/your Nephro dept re: preferences for post-exam dialysis: within 24 hr of contrast? same day as contrast given??]

Dutch:
Do you use the same contrast for ALL exams?? If not, the criteria for administering contrast to higher-risk pts must be spelled out.
My questions/comments are in brackets, e.g., does your center require labs within two weeks of the exam? One month? The orders/protocol must reflect the practice.
How do the ordering MDs get the protocol, to write the hydration orders? (what is the system?)

Let me know if I've mis-interpreted the orders; we can always re-arrange and re-write!
--- D

[DutchgirlRN]

Originally Posted by dianah

The prescribing practitioner is responsible for writing orders initiating pre-exam hydration protocol, to include (but not limited to) the following:
1. Serum BUN and creatinine drawn [within one month of iodine contrast-enhanced exam].
2. Imaging Staff to calculate eGFR 48 hours before exam.
If eGFR between 30-60ml/min:
*IV fluid: 0.45% NaCl with NaHCO3- 50mEq/Liter, 250ml bolus before and 250ml after contrast administration [probably need a rate here, e.g., 999ml/hr X 250ml].
*Mucomyst 600mg PO X 3 (total 1800 mg): One dose before contrast administration, one dose 12 hours and one dose 24 hours post-contrast administration.
If eGFR <30ml/min:
*Nephrology evaluation prior to imaging
*Consider alternative non-iodinated contrast imaging

3. Hold Metformin day of exam and for 48 hours after contrast administration.
4. If eGFR <40ml/min, hold Metformin until it is >40ml, and then for 48 hours post-contrast administration.
5. Dialysis patients: No pre-exam hydration necessary. [check w/your Nephro dept re: preferences for post-exam dialysis: within 24 hr of contrast? same day as contrast given??]

Dutch:
Do you use the same contrast for ALL exams?? If not, the criteria for administering contrast to higher-risk pts must be spelled out.
My questions/comments are in brackets, e.g., does your center require labs within two weeks of the exam? One month? The orders/protocol must reflect the practice.
How do the ordering MDs get the protocol, to write the hydration orders? (what is the system?)

Let me know if I've mis-interpreted the orders; we can always re-arrange and re-write!
--- D

Our BUN & Creatinine has to be drawn 24 hours prior to contrast. (hopefully we'll soon have istat)

Yes you're right we need a fluid rate. Today I had a CHF pt and had to run it at 125cc/hr so he was hydrated for a total of 4 hours. I think barring a CHF patient the usual time of a 250cc bolus is 30 minutes, so 500cc/hr?

I was wondering about the dialysis. I would think the dialysis would have to take place within 24 hours of the contrast?

The ordering doctor (CT exam) does not write the hydration orders. We are to have a generic order form that we have the radiologist on duty sign. That's why the item on the protocol is: An order initiating this protocol was written in the medical record by the prescribing practioner. (this sounds awkward?) also how do we know that the prescribing practioner does indeed have an order initiating this protocol in their medical records? I just think this is really awkward.

Thanks Di for your help, it is greatly appreciated!

[dianah]

Originally Posted by DutchgirlRN

Our BUN & Creatinine has to be drawn no earlier than 24 hours prior to contrast. (hopefully we'll soon have istat)

Yes you're right we need a fluid rate. Today I had a CHF pt and had to run it at 125cc/hr so he was hydrated for a total of 4 hours.

I was wondering about the dialysis. I would think the dialysis would have to take place within 24 hours of the contrast?

The ordering doctor (CT exam) does not write the hydration orders. We are to have a generic order form that we have the radiologist on duty sign. That's why the item on the protocol is: An order initiating this protocol was written in the medical record by the prescribing practioner. (this sounds awkward?) also how do we know that the prescribing practioner does indeed have an order initiating this protocol in their medical records? I just think this is really awkward.

How can the BUN/creat be drawn within 24hr, and the eGFR be calculated within 48 hr????
Have seen difft policies, some say within two weeks, some say within one month. Gotta find some evidence somewhere that supports when the labs are to be drawn . . .
Again, check with Nephro for their recommendation about when to dialyze.
The Radiologist is the MD who signs the hydration orders? I'm confused.

[DutchgirlRN]

Originally Posted by dianah

How can the BUN/creat be drawn within 24hr, and the eGFR be calculated within 48 hr????

That is strange. It reads 48 hours but my NM said the BUN/Creat needed to be done 24 hours prior to the scan. Hum...I'll ask tomorrow.

The Radiologist is the MD who signs the hydration orders? I'm confused.

Yes the radiologist is the MD who signs the hydration orders. It goes like this. If a pt is 60 y/o or older, diabetic, renal failure or has had prior renal surgery then we are to have or draw a BUN/Creat and calculate the GFR. If the GFR is under 60 then we are to pull a pre-printed order sheet with the protocol and have the radiologist sign it. That's why I'm not figuring out why the first item on the protocol says that the ordering physician (the PCP) has initiated the protocol and has that written in the patients record. 90% of the time the PCP won't have a clue that the patient will end up being hydrated so how is he/she going to already have that statement in the patient's office chart? It makes absolutely no sense to me????

We do use the same contrast on all CT exams. However the patient I had today for hydration had a GFR of 67.5 per our calculation so I called the doc about why the hydration was ordered. The doctor had calculated the GFR as 52. He used the Cock-Crofton Gault Method of calculation. This Cock-Crofton Gault Method requires a BUN/Creat and an albumin level so there's goes istat for instant results! He said it was more accurate than what we are using which is MDRD. I discussed it with the radiologist and he said maybe we should be using the CCG method? Which method do you use?

[dianah]

When we needed a policy written, years ago my Chief Rad. told me, "just write what you do."

Thus, if there's a cutoff age that requires prehydration, write it in the protocol.
If there are risk factors which, if present, require prehydration, write it.
If the Radiologist is the one who writes the prehydration orders (after reviewing the exam orders/reason and patient's hx [risk factors!]), write it in the protocol.

Our lab automatically gives an eGFR, on any Chem 7 (don't know which formula it uses).

[DutchgirlRN]

duplicate post, sorry, it's been happening alot lately??

[DutchgirlRN]

Originally Posted by dianah

When we needed a policy written, years ago my Chief Rad. told me, "just write what you do."

Thus, if there's a cutoff age that requires prehydration, write it in the protocol.
If there are risk factors which, if present, require prehydration, write it.
If the Radiologist is the one who writes the prehydration orders (after reviewing the exam orders/reason and patient's hx [risk factors!]), write it in the protocol.

Our lab automatically gives an eGFR, on any Chem 7 (don't know which formula it uses).

I can order an eGFR in place of a BUN/Creat. I got that word from my manager today. I'll have to check with the lab as to how they calculate it? Thanks again for your help di. Cheers!

BTW have you noticed that most radiologists (although brilliant) are pretty simple in other areas such as meds? I handed one a list of patient meds today and he said "I don't have a clue as to what any of those are". They were simple like Plavix, Cozaar, Actos, Claritin etc. gees!