Inform and Hydrate!
Contrast safety does not only rely on the agent. There is another incredibly important safety measure: Drinking water. A lot of it, says the Indian radiologist and medical education expert Avinash Nanivadekar.
radiology.bayer.com (rbc): Which kind of adverse events do you see after CT contrast at your institution?
Avinash Nanivadekar (AN): We have seen less adverse events than expected in the last ten years, because we have been very fussy about choosing the right contrast agent for our population.
rbc: What is the “right contrast” in that respect?
AN: Complex patients make us even more responsible for using the safest agent and making sure the protocols are in place before we inject contrast. So we choose molecules that are globally known for safety.
In addition, we screen our patients at three levels: in the wards before they come to radiology; in radiology, where we take their history; and on the table before we inject the contrast.
Safety comes first. I have not seen an anaphylactic reaction in many years. We only see very mild reactions like nausea, hives or itching and skin blisters, which we treat immediately.
The robust practice of screening and using the best molecule puts us up front as one of the best hospitals for contrast safety.
rbc: What would be the best contrast in your opinion?
AN: The best molecule is not necessarily the most expensive molecule. I think the molecule that has been historically safe globally is a good choice. We also choose the molecule we trust. We have the manufacturer who is listening to us and trying to address the problems we have faced in the past.
The best in the West does not necessarily work for us. We’ve been trying certain combinations to find the best possible solution; In MR, we use macrocyclic molecules. We also use molecules that are labelled safe and serve a certain diagnostic need, like hepatocyte-specific agents. In CT, the best molecule for us would be non-ionic and low-osmolar.
rbc: Would other radiologists agree with your view?
AN: The majority of the Indian radiologists and users of contrast media in high volumes are very risk-averse. They want best practice radiology.
The majority of centres would not compromise on the best contrast, even if it is a little expensive, because they do not want patient related adverse events at any point.
I think the majority of the hospitals in India follows the same practice. I would put it beneath any conscientious radiologist to choose a bad molecule.
rbc: Are the radiologists the ones making the choice?
AN: If radiologists do not own the choice of contrast, but contrast is a business decision instead, then yes, there will be definitely compromises in safety. I would urge my radiologist community to have the say in choosing the best molecule.
rbc: So the situation is not yet perfect. What should be done to get there?
AN: Education and awareness are one way. The second way is for radiologists to take more ownership and insist on the best possible product.
Putting Safety First
rbc: How do you update people in your hospital on safety issues?
AN: We do it once in every six months. We go back and revisit our policies. Since we do not change our contrast molecule, we do not have to really do it too much, but we practice. We train, we retrain, and again retrain until it becomes a subconscious competency.
rbc: What are the safety basics?
AN: The first basis irrespective of patients’ creatinine status is: hydrate, hydrate, hydrate. I would not keep my patient fasting. I allow them to drink liquids until the time they are on the table. That is the first parameter of patient safety.
The second simple parameter is to tell all my patients “please go and drink a lot of water”. I give them the confidence that whatever we have injected is going to come out in the urine and is going to be out of the system.
The third parameter is also a very simple basic thing. I tell them: “In case the next day you feel a little tired, nauseous, lethargic, listless, and are not passing enough urine, this is something you need to worry about. Please come back to us.”
The other thing I would tell all my technology and radiology colleagues, is that after contrast has been injected, observe the patient for 30 minutes before you remove the IV line. In case the patient needs any kind of medication, you are able to inject it. That is one safe practice we follow in the hospital.
We need to look after the patient throughout the whole procedure: Talking to the patient before assessing his kidney problems, hydration status, hydrating the patient, talking to the patient after the procedure is over, making sure the IV line does not come out for 15-30 minutes, and making sure every adverse event, however insignificant and small it may sound, is documented.
24 hours post-procedure the patient needs to be spoken to, listened to. This can save you not only embarrassment and litigation, but also bring you closer to the community of patients and clinicians. I think that is the best way to practice good radiology.
rbc: What could you still improve at your department?
AN: I think we can simplify triaging. Right now, it takes about 15 minutes in a busy set up to triage patients. Sometimes, we know we are going to make mistakes because of the high volume of patients coming in.
I would like to offset my in-patient triaging to the wards, so that they come prepared with the checklist, and I don’t have to waste my time. I don’t want to duplicate the questions. It can be irritating for the patient also.
rbc: The cost of all of this is 15 minutes of your time?
AN: For me, time is money. Absolutely.
About Avinash Nanivadekar
Avinash Nanivadekar has been working as a radiologist in the city of Pune, Maharashtra, India, for almost 25 years. He is currently the Director and Partner at a privately owned, large radiology referral center in Pune.
Avinash Nanivadekar’s has worked as a market group leader for radiology education and training for imaging sciences for Philips between 2013 and 201. This has brought him in depth experience in other countries of the ASEAN region, e.g. Indonesia, Vietnam, Myanmar, the Philippines, Thailand and Malaysia.
The entire interview (Duration: 10 minutes)