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Contrast Media

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  • 1. Contrast media
  • 2. INTRODUCTION & HISTORY <ul><li>Substances which help in better differentiation between adjacent tissues </li></ul><ul><li>Contrast media may be positive or negative </li></ul><ul><li>Substances which increase beam attenuation & help in better visualization radiologically are called as positive contrast media. </li></ul><ul><li>Intravascular iodinated CM introduced in practice by Moses Swick a urologist in 1928 </li></ul><ul><li>Used selectan and uroselectan : Pyridone ring structures. </li></ul><ul><li>Selectan and uroselectan synthesized by Binz & Roth. </li></ul>
  • 3. Mechanism of action of CM <ul><li>Beam attenuation governed by </li></ul><ul><li>-ud </li></ul><ul><li>I = I o x e </li></ul><ul><li>d=thickness of substance </li></ul><ul><li>u=linear coefficient of radiation </li></ul><ul><li>governed by 1- physical density(at. Wt.) </li></ul><ul><li>2- atomic no.(more imp.) </li></ul><ul><li>u directly propotional to at. Wt. </li></ul><ul><li>proportional to 3’rd power of at. No. </li></ul>
  • 4. Mechanism of action of CM <ul><li>Iodine being high atomic no. substance </li></ul><ul><li>increases the attenuation by increasing the linear coefficient of radiation . </li></ul><ul><ul><ul><li>Why only iodine : </li></ul></ul></ul><ul><li>high atomic no. 53 </li></ul><ul><li>very tight binding to benzene ring </li></ul><ul><li>Special property of attenuation of routinely used X ray beams called as “K-edge effect” </li></ul>
  • 5. Basic Chemistry <ul><li>Triiodinated benzene ring is the basic constituent of all contrast media. </li></ul><ul><li>Benzene ring has 6 carbons numbered 1 to 6 clockwise (Kekule) </li></ul><ul><li>Carbon 1 attachment differentiates ionic from non ionics </li></ul><ul><li>Iodine attached at position 2,4,6 carbons </li></ul>
  • 6. Basic chemistry ( contd. ) <ul><li>C3 & C5 have amide attachments to increase solubility and also to reduce protein binding. </li></ul><ul><li>At C1 in ionics acidic group with sodium or meglumine is attached </li></ul><ul><li>At C1 in non ionics amide group is attached. </li></ul>
  • 7. Basic properties <ul><li>Iodine to particle ratio : most important factor governing the attenuation </li></ul><ul><li>Iodine to particle ratio for various media: </li></ul><ul><li>ionic : monomer - 3:2 </li></ul><ul><li>dimer - 3:1 </li></ul><ul><li>non ionic : monomer - 3:1 </li></ul><ul><li>dimer - 6:1 </li></ul>
  • 8. Basic properties (contd.) <ul><li>Osmolality : </li></ul><ul><li>-Depends on no. of particles so always higher for ionic media and monomers. </li></ul><ul><li>-Contrast media classified as HOCM and LOCM . </li></ul><ul><li>-Ionic monomers called as HOCM and rest called as LOCM. </li></ul>
  • 9. Basic properties (Contd.) <ul><li>Solubility </li></ul><ul><li>Factors increasing solubility: </li></ul><ul><li>hydroxyl group </li></ul><ul><li>amide group </li></ul><ul><li>salt ( Na / Meg ) </li></ul><ul><li>Viscosity </li></ul><ul><li>Depends on : </li></ul><ul><li>particle size (most imp.) </li></ul><ul><li>temp </li></ul><ul><li>solvent </li></ul>
  • 10. Sodium VS Meglumine Yes No Bronchospasm Less Better Opacification Strong Less Diuretic High Low Viscosity Less More Vascular effects Not Crosses BBB effect Better Less Tolerance Better Less Solubility Meglumine Sodium Parameter
  • 11. Constituents <ul><li>Triiodinated benzoic acid </li></ul><ul><li>Stabilizers : calcium/ sodium edetate </li></ul><ul><li>Buffers : phosphate </li></ul><ul><li>Preservatives :not disclosed </li></ul>
  • 12. what is ideal <ul><li>Low osmolality </li></ul><ul><li>Low viscosity </li></ul><ul><li>High water solubility </li></ul><ul><li>Biological inertness </li></ul><ul><li>Safety </li></ul><ul><li>Heat and chemical stability </li></ul><ul><li>Cost effective </li></ul>
  • 13. Classification <ul><li>Ionic media : includes </li></ul><ul><li>: Monomers </li></ul><ul><li>: Dimers </li></ul><ul><li>Non ionic media : includes </li></ul><ul><li>: Monomers </li></ul><ul><li>: Dimers </li></ul><ul><li>HOCM and LOCM </li></ul>
  • 14. Ionic contrast media <ul><li>Monomers : diatriazoic acid </li></ul><ul><li>iodamic acid </li></ul><ul><li>ioglicic acid </li></ul><ul><li>iothalamic acid </li></ul><ul><li>ioxithalamic acid </li></ul>
  • 15. Ionic contrast media <ul><li>Ionic dimers : </li></ul><ul><li>ioxaglic acid </li></ul><ul><li>iocarmic acid </li></ul>
  • 16. Non ionic contrast media <ul><li>Monomers : </li></ul><ul><li>iohexol </li></ul><ul><li>iopamidol </li></ul><ul><li>ioversol </li></ul><ul><li>iopromide </li></ul><ul><li>iopentol </li></ul>
  • 17. Non ionic contrast media <ul><li>Dimers : </li></ul><ul><li>iotrol </li></ul><ul><li>iotrolan </li></ul><ul><li>iodixanol </li></ul>
  • 18. Commonly used preparations <ul><li>Ionic contrast media : </li></ul><ul><li>- monomers : diatrizoate based </li></ul><ul><li>German remedies </li></ul><ul><li>urograffin (60,76) </li></ul><ul><li>angiograffin(65) </li></ul><ul><li>Unique ( JB chemicals ) </li></ul><ul><li>trazograph ( 76,60,plus) </li></ul><ul><li>May and Baker </li></ul><ul><li>iothalamate based : conray (280,420) </li></ul>
  • 19. Commonly used preparations <ul><li>Non ionic monomers : most commonly used media </li></ul><ul><li>Nycomed </li></ul><ul><li>Omnipaque : iohexol </li></ul><ul><li>Mallinckrodt corporation </li></ul><ul><li>Optiray : ioversol </li></ul><ul><li>German remedies </li></ul><ul><li>Ultravist : iopromide </li></ul><ul><li>J B Chemicals </li></ul><ul><li>Lek-Pamidol : iopamidol </li></ul><ul><li>Bracco </li></ul><ul><li> Iopamiro : iopamidol </li></ul>
  • 20. Commonly used preparations <ul><li>Non ionic dimers : </li></ul><ul><li>German remedies </li></ul><ul><li>Isovist : iotrolan </li></ul><ul><li>Visipaque : iodixanol </li></ul>
  • 21. Pharmacodynamics <ul><li>Excretion by glomerular filtration 95% </li></ul><ul><li>Tubular excretion and protein binding negligible </li></ul><ul><li>Half life : 30-60 minutes </li></ul>
  • 22. Contrast media and body system interactions <ul><li>kidney : conc. of media (5-8 times) </li></ul><ul><li>Heart : </li></ul><ul><li>conducting system : </li></ul><ul><li>ionic CM cause bradycardia d/t Na </li></ul><ul><li>content </li></ul><ul><li>Pumping action : decreases </li></ul><ul><li>Vessels : damage to endothelium & blood cells </li></ul>
  • 23. Contrast media and body system interactions <ul><li>Brain and myelon : </li></ul><ul><li>can enter if BBB defective : chemotoxicity and electrical changes. </li></ul><ul><li>Thyroid gland : some iodide ions always present in contrast. </li></ul><ul><li>causes problems in abnormal thyroid </li></ul><ul><li>effect takes wks to appear as hormone production takes time. </li></ul>
  • 24. Contrast media side effects <ul><li>Reactions due to osmolality </li></ul><ul><li>Endothelial damage </li></ul><ul><li>Thrombosis and thrombophlebitis </li></ul><ul><li>Damage to BBB </li></ul><ul><li>Vasodilation </li></ul><ul><li>Vascular pain </li></ul><ul><li>Hypervolumia and CVS side effects </li></ul>
  • 25. Contrast media side effects <ul><li>Reactions due to chemotoxicity </li></ul><ul><li>chemotoxicity occurs due to cations </li></ul><ul><li>more common with Na than Meg </li></ul><ul><li>Damage can occur to </li></ul><ul><li>Neurons , myocardium , endothelium , </li></ul><ul><li>RBCs , kidney </li></ul>
  • 26. Contrast media side effects <ul><li>Immunological reactions </li></ul><ul><li>true allergic reactions are very very rare . Hence called as anaphylactoid or allegroid reactions . </li></ul><ul><li>Basis is </li></ul><ul><li>Histamine release </li></ul><ul><li>Inactivation of Enzymes especially ACE and C1 esterase inhibitor </li></ul><ul><li>Activation of protein cascades like coagullation,compliment and kallikrein systems </li></ul>
  • 27. Contrast media side effects <ul><li>Reactions unrelated to media </li></ul><ul><li>pyrogenic reactions ( d/t IL-2,TNF productions) </li></ul><ul><li>Vasovagal reaction </li></ul><ul><li>Hypertensive attacks in pheochromocytoma </li></ul>
  • 28. Contrast media side effects <ul><li>Limbic system involvement in reactions ( anxiety and fear ) </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Vasovagal reaction </li></ul><ul><li>Temperature elevation cardiac dysrhythmias </li></ul><ul><li>urticaria </li></ul>
  • 29. Reactions and management <ul><li>Minor reactions: 5% </li></ul><ul><li>Nausea/vomiting : </li></ul><ul><li>reassure inj.prochlorperazine (5-10 mg IM) </li></ul><ul><li>prevent aspiration </li></ul><ul><li>Mild urticaria </li></ul><ul><li>observe </li></ul><ul><li>H1 blocker( diphenhydramine 25-50mg IM/IV) </li></ul>
  • 30. Reactions and management <ul><li>Intermediate reactions- 1% </li></ul><ul><li>extensive urticaria : </li></ul><ul><li>H1 blocker + H2 blocker </li></ul><ul><li>Bronchospasm : O2 inhalation </li></ul><ul><li>MDI B2 agonist </li></ul><ul><li>inj. Theophylline </li></ul><ul><li>inj. Epinephrine SC/IV </li></ul>
  • 31. Reactions and management <ul><li>Laryngeal edema : O2 inhalation </li></ul><ul><li>intubation if required </li></ul><ul><li>inj. Epinephrine </li></ul><ul><li>Hypotension : elevate legs </li></ul><ul><li> monitor pulse & manage accordingly </li></ul>
  • 32. Reactions and management <ul><li>Severe reactions- 0.05% </li></ul><ul><li>Anaphylactoid reactions </li></ul><ul><li>c/b hypotension with tachycardia </li></ul><ul><li>IV fluids </li></ul><ul><li>Inj. Epinephrine (sc/im) </li></ul><ul><li>Inj. Hydrocort </li></ul><ul><li>O 2 inhalation </li></ul>
  • 33. Reactions and management <ul><li>Vasovagal reactions </li></ul><ul><li>c/b hypotension with bradycardia </li></ul><ul><li>O 2 inhalation </li></ul><ul><li>IV fluids </li></ul><ul><li>Inj. Atropine </li></ul>
  • 34. Reactions and management <ul><li>Pulmonary edema </li></ul><ul><li>Elevate head end </li></ul><ul><li>O 2 </li></ul><ul><li>Inj. Lasix </li></ul><ul><li>Inj. Morphin </li></ul><ul><li>Inj. Hydrocort </li></ul>
  • 35. Reactions and management <ul><li>Seizures & convulsions </li></ul><ul><li>O 2 inhalation </li></ul><ul><li>Prevent aspiration </li></ul><ul><li>Inj. Diazepam </li></ul><ul><li>Hypertensive crisis </li></ul><ul><li>O 2 </li></ul><ul><li>Nitroglycerine </li></ul><ul><li>Inj. Lasix </li></ul><ul><li>If pheochromocytoma, manage accordingly </li></ul>
  • 36. Reactions and management <ul><li>Extravasation of contrast media </li></ul><ul><li>Elevation of extremity </li></ul><ul><li>Ice packs </li></ul><ul><li>Plastic surgery consultation </li></ul><ul><li>-if large volume, </li></ul><ul><li>-skin ulceration or blistering </li></ul><ul><li>-worsening symptoms </li></ul><ul><li>Follow up until resolution </li></ul>
  • 37. Prevention is always better <ul><li>Identify high risk patients </li></ul><ul><li>Prior reaction to CM </li></ul><ul><li>Allergic conditions </li></ul><ul><li>Asthma </li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>Very old and very young </li></ul><ul><li>Paraproteinemia and increased viscosity </li></ul><ul><li>Cardiac disease </li></ul>
  • 38. Prevention is always better <ul><li>Pre medications required in </li></ul><ul><li>I. Previous reaction to CM (11 times high risk ) </li></ul><ul><li>II. History of allergic conditions </li></ul><ul><li>Medications </li></ul><ul><li>Tab Wysolone 10 mg qid 2-3 days </li></ul><ul><li>Tab Rantac 150 mg bd 2-3 days </li></ul><ul><li>Inj Hydrocort 100mg iv </li></ul><ul><li>Inj Hydrocort 100mg iv 24 hrs & 12 hrs before procedure and 100 mg iv at procedure </li></ul>
  • 39. Prevention is always better <ul><li>Proper hydration required in </li></ul><ul><li>I. paraproteinemic conditions </li></ul><ul><li>II.hyperviscocity conditions </li></ul><ul><li>Don`t allow any type of dehydration </li></ul><ul><li>IV fluids: 500- 1000 ml during procedure </li></ul><ul><li>3-3.5 Ltrs orally over next 12 hours </li></ul>
  • 40. Prevention is always better <ul><li>Drug adjustments </li></ul><ul><li>Diabetes mellitus : If on Biguanides, </li></ul><ul><li>stop at least 1 week before- avoids lactic </li></ul><ul><li>acidosis. </li></ul><ul><li>Thyroid disease : continue sulphonyl </li></ul><ul><li>ureas for at least 2-3 weeks to avoid </li></ul><ul><li>hormonal disturbance </li></ul>
  • 41. Drugs used in Management <ul><li>Epinephrine </li></ul><ul><li>1:1000 (sc/ im) contains 1mg/ml </li></ul><ul><li>1:10000 (iv) contains 1mg/10ml </li></ul><ul><li>Precautious use in </li></ul><ul><li>Cardiac disease, hypertension & Pt on </li></ul><ul><li>B-blockers </li></ul><ul><li>Atropine </li></ul><ul><li> 0.6-1.2 mg iv monitored by pulse rate </li></ul><ul><li>Precautious use in </li></ul><ul><li>Glaucoma , BHP </li></ul><ul><li>Corticosteroids: not useful in acute reactions </li></ul><ul><li> Hydrocort 100 mg iv </li></ul><ul><li> Prednisolone 10 mg oral </li></ul>
  • 42. Drugs used in Management <ul><li>Antihistaminics: both H1 & H2 blockers used </li></ul><ul><li>Diphenehydramine (H1) 50 mg </li></ul><ul><li>Cimetidine (H2) 300 mg </li></ul><ul><li>B2 agonists: used by MDI </li></ul><ul><li>Salbutamol, terbutaline </li></ul><ul><li>Lasix: 40 mg iv </li></ul><ul><li>monitor electrolytes </li></ul><ul><li>Anticonvulsants </li></ul><ul><li>Diazepam 5mg iv </li></ul><ul><li>Antihypertensives </li></ul><ul><li>phentolamine ( pheochromocytoma), Nifedipine </li></ul>
  • 43. Storage & how to use <ul><li>Room temperature </li></ul><ul><li>Dark place </li></ul><ul><li>Don`t freeze </li></ul><ul><li>Once opened use within 4 hours </li></ul><ul><li>Don`t mix with other drugs </li></ul><ul><li>Don`t prick rubber lid at the same place repeatedly </li></ul>
  • 44. Storage & how to use <ul><li>Dose : </li></ul><ul><li>Max </li></ul><ul><li>Ionics : 2-3ml/ kg </li></ul><ul><li>Nonionics: 5ml/ kg </li></ul><ul><li>Dose= 5ml/kg </li></ul><ul><li> Sr Creat </li></ul><ul><li>Don`t remove IV line as it may be needed later </li></ul><ul><li>Don`t leave the pt unattended for at least half an hour </li></ul>
  • 45. Some other facts <ul><li>Laboratory tests like urine protein, serum electrolytes may be affected so do either prior or 24 hrs after procedure. </li></ul><ul><li>Some enzymes may become elevated. </li></ul><ul><li>Breast feeding to be avoided for at least 5 days. </li></ul><ul><li>Trans placental/ milk passage can cause iodine mumps or hypothyroidism in child. </li></ul>
  • 46. <ul><li>Thank you... </li></ul><ul><li>Dr Pankaj Dixit </li></ul>

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