D. Questionnaires/letters

D.1. AN EXAMPLE OF A SUITABLE LETTER FOR THE PATIENT TO TAKE TO THE ALLGERGY CONSULTATION

Dear colleague,

(Insert patient's name and details) had a hypersensitivity reaction after the administration of a contrast agent on (insert date). 

Examination type (e.g. CT, MRI, IV.....):

Type of contrast agent:

Name of the contrast agent:

Dose administered:                                                                   ml

Route of administration (e.g. IV, IA, intra-articular, oral, local......):

Time between the injection and the start of the clinical symptoms:

Type of symptoms (describe):

Grade of the reaction according to the Ring and Messmer classification:

Grade	Dermal	Abdominal	Respiratory	Cardiovascular
1	Pruritus Flushing Urticaria Angioedema
2	Pruritus Flushing Urticaria Angioedema	Nausea Cramping	Rhinorrhea Hoarseness Dyspnea	Tachycardia (> 20 bpm) Blood pressure change (> 20 mm Hg systolic) Arrhythmia
3	Pruritus Flushing Urticaria Angioedema	Vomiting Defecation Diarrhea	Laryngeal edema Bronchospasm Cyanosis	Shock
4	Pruritus Flushing Urticaria Angioedema	Vomiting Defecation Diarrhea	Respiratory arrest	Carciac arrest

 

Treatment given during the reaction:

Outcome (e.g. follow up, ICU, return home ......):

Histamine and/or Tryptase blood tests:

Blood test performed at the time of the reaction                       Yes/No

2 hours later                                                                        Yes/No

Results:  Histamine: 

        Tryptase: 

Previous history of contrast agent reaction                                 Yes/No

If yes, please specify type of contrast agent and symptoms

Thank you for seeing the patient and performing skin testing to categorize the reaction as either allergic or non-allergic hypersensitivity, and to look for cross-reactivity so that a safer contrast agent can be recommended for future injections.

Your sincerely,

Dr (Name and details)

D.2. QUESTIONNAIRE FOR IODINE-BASED CONTRAST MEDIA ADMINISTRATION TO BE COMPLETED BY THE REFERRING CLINICIAN

 

Questionnaire for iodine-based contrast media administration to be completed by the referring clinician
		Yes	No
1.	History of moderate or severe reaction to an iodine-based contrast medium
2.	History of atopy requiring treatment
3.	History of unstable asthma
4.	Hyperthyroidism
5.	Heart failure
6.	Diabetes mellitus
7.	History of renal disease
8.	Previous renal surgery
9.	History of proteinuria
10.	Hypertension
11.	Gout
12.	Most recent measurement of serum creatinine • Value............................................. • Date ..............................................
13.	Is the patient currently taking any of the following drugs
	Metformin
	Interleukin 2
	NSAIDs
	Aminoglycosides
	ß-blockers
Completed by ______________________________________ Date ________________________

 

D.3. QUESTIONNAIRE FOR GADOLINIUM-BASED CONTRAST AGENT ADMINISTRATION TO BE COMPLETED BY THE REFERRING CLINICIAN

Questionnaire for gadolinium-based contrast agent administration to be completed by the referring clinician
		Yes	No
1.	History of moderate or severe reaction to a gadolinium-based contrast medium
2.	History of atopy requiring treatment
3.	History of unstable asthma
4.	Has the patient end-stage renal failure (eGFR < 30 ml/min/1.73m2) or is the patient on dialysis
5.	Has the patient reduced renal function* (eGFR between 30 and 60 ml/min/1.73 m2)
* Only if high-risk agents are used   Completed by ______________________________________ Date ________________________