Untitled

ESUR Guidelines
on Contrast Media
version 6.0
ESUR Guidelines
on Contrast Media
European Society of Urogenital Radiology
version 6.0
It is a great honor for the Contrast Media Safety Committee of the European So-ciety of Urogenital Radiology (ESUR) to present version 6.0 of its Contrast Media Guidelines. Since 1996 the intention of the Committee has been to cover all the safety aspects of contrast media and now that goal has been reached. Today these are the most comprehensive guidelines available. Our key aim has always been to come up with simple practical guidelines and over the years our work has been well received. Th e guidelines have been translated into 6 languages other than In version 6.0 our new questionnaires for iodine-based and MR contrast media administration to be completed by the referring clinician have been added. We have also reorganized the formal structure of our guidelines, so they are more readable and therefore more useful in your daily practice. You can see the elec-tronic version on www.esur.org, where it is also possible to submit comments and questions through our E-mail address [email protected]. Please, be aware of the fact that things may have changed rapidly aft er this booklet was printed (e.g. in the case of nephrogenic systemic fi brosis and gadolinium based contrast agents). e European Society of Urogenital Radiology hopes that the guidelines will help in your daily practice and benefi t all patients.
ESUR Contrast Media Safety CommitteeFebruary 2007 Overview
Non-renal adverse reactions
Renal adverse reactions
Gadolinium contrast media (non organ specifi c) Dialysis and contrast medium administration 22 Miscellaneous
Eff ects of iodinated contrast media on blood and endothelium Contrast media and catecholamine producing tumours (Pheochromocytoma and Paraganglioma)Pregnancy and lactation Interaction with other drugs and clinical tests Safety of liver specifi c MR contrast media Questionnaire for iodine-based contrast media
Questionnaire for MRI contrast media
Publications
Contrast Media Safety Committee
1. AN OVERVIEW
is overview summarizes some of the most important parts of the Guidelines and is intended for quick reference only. For specifi c problems, always refer to the relevant Guideline. Please notice the statement about gadolinium contrast agents at the end of the guideline.
IODINATED CONTRAST
GADOLINIUM CONTRAST
MEDIA
(non-organ specifi c)
At time of referral, identify patients at increased risk of reaction*
Before the examination
e referring physician should complete the appropriate questionnaire Overview
At the time of examination
• Use a non-ionic contrast medium.
After the examination, delayed adverse effects may occur
Pregnant patients
Lactating patients
Laboratory tests
Radioisotope tests and/or treatment
tests and treatment for 2 months aft er iodinated contrast medium administration.
Overview
IODINATED CONTRAST MEDIA
GADOLINIUM CONTRAST
MEDIA
(non-organ specifi c)
At time of referral*
measured within 7 days of contrast medium administration in patients• With previously raised serum the possibility of raised serum creatinine • Renal disease• Renal surgery• Proteinuria• Diabetes mellitus• Hypertension• Gout • Recent nephrotoxic drugs e referring physician should complete the appropriate questionnaire Overview
Before the examination
In patients with a raised serum creatinine:• Consider an alternative imag- ing method not using iodinated contrast media examination, stop nephrotoxic drugs, mannitol and loop diuretics At the time of the examination
After the examination
sure serum creatinine at 48 hours aft er contrast medium administra-tion to check if metformin can be restarted.
• Dialysis immediately aft er contrast medium administration is unneces-sary.
Overview
2. NON-RENAL ADVERSE REACTIONS
ACUTE ADVERSE REACTIONSDefi nition: An adverse reaction which occurs within 1 hour of contrast medium injection.
Classifi cation
Severe vomitingMarked urticariaBronchospasmFacial/laryngeal edemaVasovagal attack Hypotensive shockRespiratory arrestCardiac arrestConvulsion Iodinated Contrast Media
RISK FACTORS FOR ACUTE REACTIONS
Patient with a history of:• Previous moderate or severe acute reaction (see “Classifi cation” above) to an iodinated agent.
• Asthma.
• Allergy requiring medical treatment.
TO REDUCE THE RISK OF AN ACUTE REACTION
• Use a non-ionic contrast medium.
• Keep the patient in the Radiology Department for 30 min aft er contrast medium injection.
• Have the drugs and equipment for resuscitation readily available (see “Management of Acute Reactions”, p.13).
Non-renal Adverse Reactions
• Consider an alternative test not requiring an • Use a diff erent iodinated agent for previous • Consider the use of premedication. Clinical evidence of the eff ectiveness of premedication is limited. If used, a suitable premedication regime is prednisolone 30 mg (or methylpred-nisolone 32 mg) orally given 12 and 2 hours before contrast medium.
Extravascular admin-
When absorption or leakage into the circulation istration of iodinated
is possible, take the same precautions as for contrast media
Gadolinium Contrast Media (non organ specifi c)
Note: Th
e risk of an acute reaction to a gadolinium contrast agent is signifi - cantly lower than the risk with an iodinated contrast agent.
RISK FACTORS FOR ACUTE REACTIONS
Patients with a history of• Previous acute reaction to gadolinium contrast agent.
• Asthma• Allergy requiring medical treatment.
e risk of reaction is not related to the osmolality of the contrast agent: the low doses used make the osmolar load very small.
TO REDUCE THE RISK OF AN ACUTE REACTION
• Keep the patient in the Radiology Department for 30 min aft er contrast medium injection.
• Have the drugs and equipment for resuscitation read-ily available (see “Management of Acute Reactions”).
• Consider an alternative test not requiring a gado- • Use a diff erent gadolinium agent for previous reactors Non-renal Adverse Reactions
• Consider the use of premedication. Th evidence of the eff ectiveness of premedication. If used, a suitable premedication regime is prednisolone 30 mg (or methylprednisolone 32 mg) orally given 12 and 2 hours before contrast medium.
MANAGEMENT OF ACUTE REACTIONS
First line emergency drugs and instruments which should be in the examination room.
Antihistamine H1 – suitable for injection I.V. Fluids – normal saline or Ringers solution Simple guidelines for fi rst line treatment of acute reactions to
contrast media
Nausea/Vomiting
Transient: Supportive treatment
Severe, protracted: Appropriate antiemetic drugs should be considered.
Urticaria
Scattered, transient: Supportive treatment including observation.
Scattered, protracted: Appropriate H1-antihistamine intramuscularly or intrave-
nously should be considered. Drowsiness and/or hypotension may occur.
Profound: Consider Adrenaline 1:1,000, 0.1-0.3 ml (0.1-0.3 mg) intramuscularly in
adults, 0.01 mg/kg intramuscularly up to 0.3 mg max. in children. Repeat as needed.
Non-renal Adverse Reactions
Bronchospasm
1. Oxygen by mask (6-10 l/min)
2. β-2-agonist metered dose inhaler (2-3 deep inhalations)
3. Adrenaline
Intramuscular: 1:1,000, 0.1-0.3 ml (0.1-0.3 mg) [use smaller dose in a patient with coronary artery disease or elderly patient] In pediatric patients: 0.01 mg/kg up to 0.3 mg max. Intramuscular: 1:1,000, 0.5 ml (0.5 mg), In pediatric patients: 0.01 mg/kg intramuscularly Laryngeal edema
1. Oxygen by mask (6 – 10 l/min)
2. Intramuscular adrenaline (1:1,000), 0.5 ml (0.5 mg) for adults, repeat as needed.
Hypotension
Isolated hypotension1. Elevate patient’s legs2. Oxygen by mask (6-10 l/min)3. Intravenous fl uid: rapidly, normal saline or lactated Ringer’s solution4. If unresponsive: adrenaline: 1:1,000 , 0.5 ml (0.5 mg) intramuscularly, repeat Vagal reaction (hypotension and bradycardia)1. Elevate patient’s legs2. Oxygen by mask (6-10 l/min)3. Atropine 0.6-1.0 mg intravenously, repeat if necessary aft er 3-5 min, to 3 mg total (0.04 mg/kg) in adults. In pediatric patients give 0.02 mg/kg intrave-nously (max. 0.6 mg per dose) repeat if necessary to 2 mg total. 4. Intravenous fl uids: rapidly, normal saline or lactated Ringer’s solution Generalized anaphylactoid reaction
1. Call for resuscitation team
2. Suction airway as needed
3. Elevate patient’s legs if hypotensive
4. Oxygen by mask (6 – 10 l/min)
5. Intramuscular adrenaline (1:1,000), 0.5 ml (0.5 mg) in adults. Repeat as
needed. In pediatric patients 0.01 mg/kg to 0.3 mg (max. dose) 6. Intravenous fl uids (e.g. normal saline, lactated Ringer’s)7. H1-blocker e.g. diphenhydramine 25-50 mg intravenously Non-renal Adverse Reactions
Defi nition: An adverse reaction which occurs 1 hour to 1 week aft er contrast medium injection.
TYPE OF REACTION
• A variety of late symptoms (e.g. nau- sea, vomiting, headache, musculosk-eletal pain, fever) have been described following contrast medium, but many are not related to contrast medium.
other drug eruptions are true late late adverse reactions. Th SKIN REACTIONS FOLLOWING IODINATED CONTRAST
MEDIUM ADMINISTRATION
• Previous contrast medium reaction• Interleukin-2 treatment Generally not recommendedPatients who have had a previous serious late adverse reaction can be given steroid prophylaxis (see “To reduce the risk of an acute reaction”, p. 12) Symptomatic and similar to the management of other drug induced skin reactions Tell patients who have had a previous contrast reaction or who are on interleu-kin-2 treatment that a late skin reaction is possible and that they should contact a doctor if they have a problem.
Non-renal Adverse Reactions
Defi nition: An adverse reaction which usually occurs more than 1 week aft er contrast medium injection.
TYPE OF REACTION
NEPHROGENIC SYSTEMIC FIBROSIS
Patients with severely reduced renal function (GFR < 30ml/min) or on hemodialysis or peritoneal dialysis Please consult www.esur.org for the latest information or contact [email protected] THYROTOXICOSIS
• Patients with untreated Graves’ disease• Patients with multinodular goiter and thyroid autonomy, especially if they are elderly and/or live in area of dietary iodine defi ciency • Iodinated contrast media should not be given
to patients with manifest hyperthyroidism.
• Prophylaxis is generally not necessary.
• In selected high-risk patients, prophylactic
treatment may be given by an endocrinologist;
this is more relevant in areas of dietary iodine
defi ciency.
• Patients at risk should be closely monitored by
endocrinologists aft er iodinated contrast medium
injection.
• Intravenous cholangiographic contrast media
should not be given to patients at risk.
Non-renal Adverse Reactions
3. RENAL ADVERSE REACTIONS
Defi nition: Contrast medium nephrotoxicity is a condition in which an impairment in renal function (an increase in serum creatinine by more than 25% or 44μmol/l (0.5 mg/dl)) occurs within 3 days following the intravascular administration of a contrast medium (CM) in the absence of an alternative etiology.
RISK FACTORS FOR CONTRAST MEDIUM INDUCED
NEPHROPATHY
• Raised serum creatinine particularly secondary • Dehydration• Congestive heart failure• Gout• Age over 70• Concurrent administration of nephrotoxic drugs e.g. non-steroid anti-infl ammatory drugs.
RISK OF IODINATED CONTRAST MEDIA IN PATIENTS TAKING
METFORMIN
Metformin is excreted unchanged in the urine. In the presence of renal failure, either pre-exist-ing or induced by iodinated contrast medium, metformin may accumulate in suffi Renal Adverse Reactions
Time of referral
ELECTIVE EXAMINATION
1) IDENTIFY PATIENTS WITH RAISED SERUM CREATININE
• Patients who will receive intra-arterial contrast medium• Patients who have a history suggesting the possibility of raised creatinine: • Renal disease• Renal surgery• Proteinuria• Diabetes mellitus• Hypertension• Gout• Recent nephrotoxic drugs 2) IDENTIFY DIABETIC PATIENTS TAKING METFORMIN
Depending on serum creatinine level, metformin will have to be stopped either before or at the time of contrast medium administration (see “Before the examination”, page 19) EMERGENCY EXAMINATION
1) Identify patients with raised serum creatinine if possible.
2) Identify patients taking metformin
• Measure serum creatinine if the procedure can be deferred until the result is • In extreme emergency, if serum creatinine measurement cannot be obtained, follow the protocol for patients with raised serum creatinine as closely as clinical circumstances permit.
Renal Adverse Reactions
Before the examination
ELECTIVE EXAMINATION
• Consider an alternative imaging method not • Stop nephrotoxic drugs, mannitol and loop diuretics at least 24 hours before contrast • Start hydration. A suitable intravenous regime is 1ml/kg b.w. per hour of normal saline for at least 6 hours before and aft er the procedure. In hot climates the volume should be increased.
• If serum creatinine is normal stop metformin from the time of contrast medium administra-tion for 48 hours. Only restart metformin if serum creatinine remains normal.
• If serum creatinine is raised stop metformin 48 hours before contrast medium administration and remain off metformin for 48 hours aft er contrast medium. Only restart metformin if serum creatinine is unchanged 48 hours aft er contrast medium.
EMERGENCY EXAMINATION
• Consider an alternative imaging method not • Start intravenous hydration as early possible before contrast medium administration (See before “Elective Examination”).
Renal Adverse Reactions
• If serum creatinine is normal, follow instruc- • If serum creatinine is abnormal (or unknown), weigh the risks and benefi ts of contrast medium administration and consider an alternate imaging method. If contrast medium is deemed essential take the following precautions: Metformin therapy should be stopped.
Th e patient should be hydrated (E.g. at least 1 ml per hour per kg b.w. of intravenous normal saline up to 24 hours aft er contrast medium administration – In warm areas more fl uid should be given).
Monitor renal function (serum creatinine), Look for symptoms of lactic acidosis (vomiting, somnolence, nausea, epigastric pain, anorexia, hyperpnea, lethargy, diarrhea and thirst). Blood test results indicative of lactic acidosis: pH < 7.25 and lactic acid > 5 mmol.
Time of examination
medium consistent with a diagnostic result.
After the examination
Measure serum creatinine at 48 hours aft er contrast medium ad-ministration. If it is within normal levels, metformin can be restarted.
Renal Adverse Reactions
Note: None of the pharmacological manipulations (with renal vasodilators,
receptor antagonists of endogenous vasoactive mediators or cytoprotective
drugs) has yet been shown to off er consistent protection against contrast
medium induced nephropathy.
GADOLINIUM CONTRAST MEDIA (NON-ORGAN SPECIFIC) MR Examinations
• Th
e risk of nephrotoxicity is very low when gadolinium contrast media are • Please consult www.esur.org for the latest recommendations on avoiding Radiographic Examinations
• Gadolinium contrast media should not be used for radiographic examinations
• Gadolinium contrast media are more nephrotoxic than iodinated contrast in DIALYSIS AND CONTRAST MEDIUM ADMINISTRATIONAll contrast media, iodinated and gadolinium, can be removed by hemodi-alysis or peritoneal dialysis. However, there is no evidence that hemodialysis protects patients with impaired renal function from contrast medium induced nephropathy.
PATIENTS ON DIALYSIS WHO RECEIVE IODINATED OR
GADOLINIUM CONTRAST MEDIUM
• Avoid osmotic and fl uid overload• Correlation of time of the contrast medium injection with the hemo-dialysis session is unnecessary.
remove contrast medium is unnecessary.
Renal Adverse Reactions
4. MISCELLANEOUS
TYPE OF INJURIES
• Most injuries are minor. • Severe injuries include skin ulceration, soft tissue necrosis, and compartment syndrome RISK FACTORS
• Use of a power injector.
• Less optimal injection sites including lower • Large volume of contrast medium.
• High osmolar contrast media.
• Inability to communicate• Fragile or damaged veins• Arterial insuffi • Compromised lymphatic and/or venous drainage.
• Obesity TO REDUCE THE
• Intravenous technique should always be me- ticulous using appropriate sized plastic cannula placed in a suitable vein to handle the fl ow rate used during the injection.
• Test injection with normal saline • Use non-ionic iodinated contrast medium TREATMENT
• Conservative management is adequate in most • limb elevation• apply ice packs• careful monitoring • If a serious injury is suspected, seek the advice Miscellaneous
PULMONARY EFFECTS OF IODINATED CONTRAST MEDIA PULMONARY ADVERSE
PATIENTS AT HIGH RISK
• History of asthma • History of pulmonary hyperten- TO REDUCE THE RISK OF
PULMONARY ADVERSE
EFFECTS OF IODINATED CONTRAST MEDIA ON BLOOD AND ENDOTHELIUM The clinically important adverse effect of iodinated contrast media
on blood and endothelium is thrombosis.
It is recognized that:
• All contrast media have anticoagulant properties, especially ionic agents.
• High osmolar ionic contrast media may induce thrombosis due to endothelial
damage, particularly in phlebographic procedures.
• Drugs and interventional devices that decrease the risk of thromboembolic complications during interventional procedures minimize the importance of the eff ects of contrast media.
Guidelines
• Meticulous angiographic technique is mandatory and is the most important
factor in reducing thromboembolic complications.
• Low- or isoosmolar contrast media should be used for diagnostic and interventional angiographic procedures including phlebography.
Miscellaneous
CONTRAST MEDIA AND CATECHOLAMINE PRODUCING TUMORS (PHEOCHROMOCYTOMA AND PARAGANGLIOMA) PREPARATION
Tumor localisation when catecholamine-producing tumor detected biochemically
a) Before intravenous contrast medium (iodinated or gadolinium): α and
β-adrenergic blockade with orally administered drugs under the supervision
of the referring physician is advised. Further α-blockade with intravenous
phenoxy-benzamine is not necessary.
b) Before intra-arterial iodinated contrast medium: α and β-adrenergic block-
ade with orally administered drugs and α-blockade with intravenous phenoxy-
benzamine under the supervision of the referring physician are recommended.
Characterisation of incidentally detected adrenal mass.
No special preparation
TYPE OF CONTRAST MEDIUM WHICH SHOULD BE USED
Iodinated: non-ionic agent.
Gadolinium: any agent, ionic or non-ionic
IODINATED AGENTS
GADOLINIUM AGENTS
Pregnancy
pregnancy, thyroid func-tion should be checked in the neonate during the fi rst week. Lactation
Miscellaneous
Pregnant
or lactating
with renal
impairment
information about NSF in pregnant and lactating patients.
INTERACTION WITH OTHER DRUGS AND CLINICAL TESTS RECOMMENDATION
historyKeep a proper record of the contrast medium injection (time, dose, name)Do not mix contrast media with other drugs in tubes and syringes DRUGS NEEDING SPECIAL ATTENTION
Refer to “Renal adverse reactions” (page 17) CisplatinAminoglycosidesNon steroid anti-infl ammatory drugs β-blockers may impair the response to treatment of bronchospasm induced by contrast medium Refer to “Late adverse reactions” (page 15) Miscellaneous
BIOCHEMICAL ASSAYS
Do not perform non-emergency biochemical analysis of blood and urine collected within 24 hours of contrast medium injection.
ISOTOPE STUDIES AND/OR TREATMENT
Patients undergoing therapy with radioactive iodine should not have received iodinated contrast media for at least two months before treatment.
Isotope imaging of the thyroid should be avoided for two months aft er iodinated contrast medium injection.
injection for at least 24 hours before the isotope study Statement:
Contraindication
Type and severity of reactions:
minor (e.g. headache, nausea, sensation of heat, altered taste) and self-resolving. • Allergy-like reactions occur rarely. To reduce the risk:
output and shortest scanning time to allow a diagnostic examination.
Miscellaneous
Treatment:
“Non-renal adverse reaction”page (11). SAFETY OF LIVER SPECIFIC MR CONTRAST MEDIA Types of adverse reactions
Similar to reactions observed with other types of contrast media such as nausea, vomiting, urticaria, rash, generalized anaphylactoid reactions. Back pain may also occur with superparamagnetic iron oxides Serious life threatening reactions are rare Patients < 18 years old
Contraindications
Iron oxides
Known allergy or hypersensitiv-ity to parenteral iron or dextran Manganese based contrast media
Known allergy to the preparation, Pregnancy, Lactation, Severe liver impairment Gadolinium based contrast media
Cautions
Iron oxides
In patients with hemosiderosis or hemochromatosis: iron-overload may be aggravated.
Manganese based contrast media
Gadolinium based contrast media
• Agent with high hepatocyte
Miscellaneous
RECOMMENDED
ACTION
Contra indications
soluble contrast mediaIn neonates and patients at risk of leak-age into mediastinum and/or lungs use low- or isoosmolar contrast media Cautions
Complications
Miscellaneous
QUESTIONNAIRE
to be completed by the referring clinician.
FOR IODINE-BASED CONTRAST MEDIA ADMINISTRATION 1. History of moderate or severe reaction to an iodinated contrast medium 2. History of allergy requiring treatment 12. Most recent measurement of serum creatinine• Value………………………………………• Date ……………………………………….
13.Is the patient currently taking any of the following drugs• Metformin for treatment of diabetes Completed by _______________________Date _________________ Questionnaire
QUESTIONNAIRE
to be completed by the referring clinician.
FOR MRI CONTRAST MEDIA ADMINISTRATION.
1. History of moderate or severe reaction to a MRI contrast medium 2. History of allergy requiring treatment 4. Has the patient end-stage renal failure (eGFR < 30 ml/min/1.73m2) or is the patient on dialysis 5. History of hemosiderosis or hemochromatosis Completed by _______________________Date _________________ Questionnaire
ESUR PUBLICATIONS
omsen HS, Morcos SK and members of contrast media safety committee of the European Society of Urogenital Radiology (ESUR). Contrast media and metformin. Guidelines to diminish the risk of lactic acidosis in non-insulin dependent diabetics aft er administration of contrast media. Eur Radiol 1999; 9: 738-740. omsen HS, Webb JAW and members of contrast media safety committee of the European Society of Urogenital Radiology (ESUR). Contrast Media Induced Nephrotoxicity: A consensus report. Eur Radiol 1999; 9: 1602-1613.
omsen HS, Webb JAW and members of contrast media safety committee of the European Society of Urogenital Radiology (ESUR). Prevention of generalized reactions to contrast media: A consensus report and guidelines. Eur Radiol 2001; 11: 1720-1728.
omsen HS, Almén T, Morcos SK, Members of Contrast Media Safety Committee of European Society of Urogenital Radiology. Gadolinium-con-taining contrast media for radiographic examinations: a position paper. Eur Radiol 2002; 12: 2600-2605 5. Bellin M-F, Jakobsen JÅ, Tomassin I, Th of the Contrast Media Safety Committee of the European Society of Urogenital Radiology. Contrast medium extravasation injury: guidelines for prevention and management. Eur Radiol 2002; 12: 2807-2812.
omsen HS, Webb JAW, Members of the Contrast Media Safety Committee of European Society of Urogenital Radiology. Dialysis and contrast media. Eur Radiol 2002; 12: 3026-1629.
omsen HS, Morcos SK, Members of the Contrast Media Safety Committee of the European Society of Urogenital Radiology (ESUR). Late adverse reactions to intravascular iodinated contrast media. Eur Radiol 2003; 13: 181-184.
omsen HS, Morcos SK, Members of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). Management of acute adverse reactions to contrast media. Eur Radiol 2004; 14: 476-481.
Publications
omsen HS, Morcos SK, Members of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). Eff ect of iodinated contrast media on thyroid function in adults. Eur Radiol 2004; 14: 902-906.
omsen HS, Morcos SK, Members of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR) In which patients should serum-creatinine be measured before contrast medium administration? Eur Radiol 2005; 15; 749-754.
omsen HS, Morcos SK, Members of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). Safety of ultrasound contrast agents. Eur Radiol 2005; 15: 941-945 omsen HS, Morcos SK, Members of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). Th of iodinated and gadolinium contrast media during pregnancy and lacta-tion. Eur Radiol 2005; 15: 1234-1240.
omsen HS, Exley CM, Members of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). Contrast Media: Interaction with other drugs and clinical tests. Eur Radiol 2005; 15: 1463-1468 of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). Safety of MR liver specifi c contrast media. Eur Radiol 2005; 15: 1607-1614.
omsen HS, Morcos SK, Molen AJvd, Members of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). Eff ects of iodinated contrast media on blood and endothelium. Eur Radiol 2006; 16: 1041-1049.
omsen HS (ed). Contrast media. Safety issues and ESUR Guidelines. omsen HS (in preparation) Reducing the risk of iodine based and MRI contrast media administration: Recommendation for a questionnaire at time of booking. Publications
CONTRAST MEDIA SAFETY COMMITTEE
omsen (DK) Chairman

Sameh K. Morcos (UK)
Torsten Almén (SE)
Peter Aspelin (SE)
Per Liss (SE)
Marie-France Bellin (FR)
Raymond Oyen (BE)
Edwin T. den Braber (DE) Mallinckrodt - Tyco Healthcare

Hugo Flaten (NO) GE Healthcare Diagnostics

Gertraud Heinz-Peer (AT)
Jean-Marc Idée (FR) Guerbet

Andrea Löwe (DE) Schering

Jarl Å. Jakobsen (NO)
Alberto Spinazzi (IT) Bracco

Fulvio Stacul (IT)
Judith A. W. Webb (GB)
www.esur.org

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