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Response

296 responses were received; 214 from diagnostic departments and 82 from radiotherapy departments. Responses from both diagnostic and radiotherapy departments came from all four countries of the UK: 260 from England, 3 from Northern Ireland, 7 from Scotland and 25 from Wales. See Appendix B for the responses and Appendix C for the freehand responses.

Mechanisms for supply and administration

188 departments (80.3% of those who responded) had patient group directions (PGDs) in place, 62 (26.5%) used patient specific directions (PSDs) and 18 departments (7.7%) had radiographer supplementary prescribers (SPs) in place. Just 11 respondents used local policies or were in the process of setting up PGDs.

Who injects?

Of those who responded, there were seven diagnostic imaging departments where only radiologists undertook intravenous injections. The vast majority used radiographers (86 - 51.5%) or a combination of radiologists and radiographers (74 - 44.3%). In radiotherapy departments, almost all intravenous injections were undertaken by radiographers (65 - 92.9%).  Radiologists tended to inject if IV access was deemed difficult or if the patient was a child.

IV training for radiographers

Of those responding, 128 (54.5%) of radiographers from both diagnostic and radiotherapy departments undertaking intravenous injections had undertaken a College of Radiographers (CoR) accredited IV course and 151 (64.3%) took local in-house training including courses run by the trust. Some employing authorities required the radiographers to undertake local courses even if they had completed the SCoR accredited course.

Contrast agents used in diagnostic imaging

The most common contrast agent used was Omnipaque (79 respondents), followed by Gastrografin (73 respondents).

Contrast agent, number and percentage of responses is given here:

Omnipaque 79 56.8%
Gastrografin 73 52.5%
Niopam 54 38.8%
Gadovist 53 38.1%
Primovist 51 36.7%
Dotarem 43 30.9%
E-Z-HD 43 30.9%
Magnevist 40 28.8%
Visipaque 39 28.1%
MultiHance 28 20.1%
Ultravist 15 10.8%
Prohance 13 9.3%
SonoVue 8 5.8%

Contrast agents used in radiotherapy

The most common contrast agent used was Omnipaque (28 respondents), followed by Gastrografin (24 respondents).

Contrast agent, number and percentage of responses is given here:

Omnipaque 28 54.9%
Gastrografin 24 47.1%
Niopam 20 39.2%
Visipaque 15 29.4%
E-Z-HD 4 7.8%
Ultravist 4 7.8%
Optiray 4 7.8%
SonoVue 1 1.9%

Other medicines used

The most common other medicine administered was saline (122 respondents), followed by Buscopan (101 respondents).

In diagnostic radiography, the medicine, number and percentage of respondents is given here:

Saline 100 66.7%
Buscopan 93 62%
Picolax 51 34%
Glucagon 33 22%
Frusemide 33 22%
Maxalon 26 17.3%
Kleen-prep 24 16%
Lignocaine 17 11.3%
Fleet 10 6.7%
Citramag 7 4.7%

In radiotherapy, the medicine,  number and percentage of respondents is given here:

Saline 22 68.8%
Buscopan 8 25%
Maxalon 4 12.5%
Lignocaine 4 12.5%
Glucagon 2 6.3%
Picolax 2 6.3%
Citramag 1 3.1%

Radiographers and sedatives

Very few radiographers administer sedatives; just three (1.8%) of respondents from diagnostic imaging departments and six (9.5%) of respondents from radiotherapy departments.  Lorazipam was the most common medicine quoted.  Sedation may be required in diagnostic radiography for micturating cystourethrograms and arthrograms, for example.

Radiographers and antibiotics

Nearly a quarter of respondents from radiotherapy departments (15 – 24.6%) supply and/or administer antibiotics. Some of these are from the clinical management plan (CMP) used by supplementary prescribers.  Just four (2.5%) of diagnostic departments supply antibiotics although one respondent did comment:

We would be keen for this to happen as prescribing treatment antibiotics for MCUG patients who have reflux would streamline the whole procedure rather than waiting for or finding a radiologist to prescribe.

Radiographers and pain relief

Only 14 diagnostic departments (8.3%) have radiographers supplying and/or administering pain relief; this may be before biopsy, aspiration or steroid injection. This figure is much higher in radiotherapy at 30 (47.6% of respondents). Entonox, pethidine and lignocaine were cited as useful medicines used to provide pain relief.

Radiographers and radionuclide imagining (nuclear medicine)

Of those responding, 52 (31.1%) from diagnostic imaging departments and 5 (8.1%) from radiotherapy departments had radiographers who administered radiopharmaceuticals.

Radiopharmaceutical administration comes under two pieces of legislation; medicines and medical devices (being regulated by the Medicines and Healthcare Products Regulatory Agency (MHRA)) and Ionising Radiation (Medical Exposure) Regulations ( IR(ME)R).  This is overseen by the Administration of Radioactive Substances Advisory Committee (ARSAC).

Nuclear medicine technologists work alongside radiographers in radionuclide imaging. Technologists cannot use PGDs nor can they train to become supplementary prescribers.

Other drugs administered by radiographers working in radionuclide imaging departments included frusemide and pharmacological stress agents such as adenosine.


Adverse events and reactions

Respondents in both diagnostic and radiotherapy departments were asked to say how many times, during the past year, a patient had had an adverse event under seven categories.

CATEGORY NOT AT ALL 1-5 6-10 MORE THAN 10
Severe (protracted) nausea/vomiting 114 (65.1%) 55 (31.4%) 2 (1.1%) 4 (2.2%)
Urticaria 86 (47.3%) 81 (44.5%) 9 (4.9%) 6 (3.2%)
Bronchospasm 144 (86.7%) 21 (12.6%) 0 1 (0.6%)
Laryngeal oedema 158 (94.6%) 8 (4.8%) 0 1 (0.6%)
Hypotension 137 (81.1%) 26 (15.3%) 3 (1.8%) 3 (1.8%)
Anaphylactoid reaction 135 (78.5%) 33 (19.1%) 3 (1.7) 1 (0.6)
Contrast medium extravasation 68 (35.4%) 83 (43.2%) 16 (8.3) 25 (13%)

As can be seen from the above table, the commonest complication is contrast agent extravasation.

This is generally as a result of the use of automated power injection and/or when large volumes are injected which leads to tissue damage. Most extravasations result in minimal swelling or erythema, however severe skin necrosis and ulceration may occur and compartment syndrome may result. The Royal College of Radiologists publishes guidelines on treatment of extravasation within its document ‘Standards for intravascular contrast agent administration to adult patients’, (2nd ed., RCR, 2010). Forty-five respondents (65.2%) who reported extravasation used the RCR guidelines or local amendments to the RCR standards and 38 (55.1%) had a local policy detailing the appropriate treatment.

One respondent commented:

We've had 2 very serious extravasation incidents which were thoroughly investigated and found that all policies and procedures were followed; however we felt that information for treating such cases was patchy and difficult to obtain. There was also no one place to go to for expert advice.

The adverse events caused by reaction to the contrast media itself were relatively unusual and most departments recorded no adverse reactions or events at all.

One department had two episodes of anaphylactoid reaction:

Two episodes of anaphylactoid reaction required Crash team in and resulted in A&E admission. Both situations were managed well without an adverse outcome.

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