Contrast Agents dr shabeel pn
Contrast Agents <ul><li>Compounds used to improve the visibility of internal bodily structures in an image. </li></ul><ul>...
Commonly used iodinated contrast agents   Iso Osmolar 290 320 Non-ionic dimer Iodixanol (Visipaque 320) 884 350 Non-ionic ...
Ionic Contrast Agents <ul><li>> 10 million diagnostic procedures / year  </li></ul><ul><li>Conventional ionic contrast rea...
Anaphylactoid (idiosyncratic) <ul><li>unpredictable  </li></ul><ul><li>dose independent  </li></ul><ul><li>prevalence 1-2%...
Chemotoxic <ul><li>predictable  </li></ul><ul><li>dose dependent  </li></ul><ul><li>due to osmolality or ionic composition...
Risk Factors  <ul><li>Previous contrast reaction either moderate or severe </li></ul><ul><ul><li>asthma  </li></ul></ul><u...
Late Reactions  <ul><li>1 hr to 1 week following contrast injection  </li></ul><ul><li>Headache, myalgias, fever, skin rea...
Severity of Reactions - Minor  <ul><li>Nausea & vomiting  </li></ul><ul><li>Urticaria  </li></ul><ul><li>Pruritis  </li></...
Severity of Reactions - Moderate  <ul><li>Faintness  </li></ul><ul><li>Facial edema  </li></ul><ul><li>Laryngeal edema  </...
Severity of Reactions - Severe  <ul><li>Pulmonary edema  </li></ul><ul><li>Respiratory arrest  </li></ul><ul><li>Cardiac a...
Renal Toxicity  (increased serum creatinine by more than 25% or > 0.5 mg%)   <ul><li>2-7%  </li></ul><ul><li>Risk Factors ...
Renal Toxicity  (increased serum creatinine by more than 25% or > 0.5 mg%)   <ul><li>direct relationship between serum cre...
Metformin (Glucophage)  <ul><li>oral diabetic agent  </li></ul><ul><li>patients with renal insufficiency may develop lacti...
Screening Creatinine  <ul><li>Which patients need screening creatinine? Consider if patient has one of the following risk ...
Treatment Contrast Reactions  <ul><li>Nausea & Vomiting </li></ul><ul><ul><li>usually self-limited  </li></ul></ul><ul><ul...
Treatment Contrast Reactions  <ul><li>Hypotension </li></ul><ul><li>Bradycardia (Vasovagal) </li></ul><ul><ul><li>elevate ...
Treatment Contrast Reactions <ul><li>Bronchospasm or laryngeal edema </li></ul><ul><ul><li>O2 3 L/min  </li></ul></ul><ul>...
Treatment Contrast Reactions <ul><li>Anaphylactoid   </li></ul><ul><li>O2 3 L/min  </li></ul><ul><li>IV normal saline  </l...
Treatment Contrast Reactions <ul><li>Seizures   </li></ul><ul><ul><li>protect airway  </li></ul></ul><ul><ul><li>Diazepam ...
Extravasation <ul><li>Elevate extremity  </li></ul><ul><li>Ice pack 3x day  </li></ul><ul><li>Observe for 2-4 hours if vol...
Extravasation <ul><li>Plastic Surgery Consultation </li></ul><ul><li>ionic > 30 ml  </li></ul><ul><li>nonionic > 100 ml  <...
Pretreatment Protocols <ul><li>Reduces minor reactions </li></ul><ul><li>Benadryl 50 mg IM or PO 1 hr before procedure  </...
Pretreatment Protocols <ul><li>Reduction of Nephrotoxicity </li></ul><ul><ul><li>Creatinine level > 2 mg/dl </li></ul></ul...
Risk of Nephropathy <ul><li>A recent meta analysis: Radiology: Volume 239: May 2006 p.392-397: Drs Rao & Newhouse </li></u...
ACR Manual on Contrast Media  <ul><li>guide for radiologists in the use of iodinated contrast media </li></ul><ul><li>h tt...
References of Interest <ul><li>Guidelines for Contrast Media from the European Society of Urogenial Radiology: AJR:181, De...
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Contrast Agents Introduction to Radiology

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Contrast Agents Introduction to Radiology

  1. 1. Contrast Agents dr shabeel pn
  2. 2. Contrast Agents <ul><li>Compounds used to improve the visibility of internal bodily structures in an image. </li></ul><ul><li>Types: </li></ul><ul><ul><li>Radiographic agents based on iodine </li></ul></ul><ul><ul><ul><li>ionic or non-ionic agents </li></ul></ul></ul><ul><ul><ul><ul><li>Monomer or Dimer </li></ul></ul></ul></ul><ul><ul><ul><li>high osmolar, low osmolar, iso osmolar </li></ul></ul></ul>
  3. 3. Commonly used iodinated contrast agents Iso Osmolar 290 320 Non-ionic dimer Iodixanol (Visipaque 320) 884 350 Non-ionic Iohexol (Omnipaque 350) 796 370 Non-ionic monomer Iopamidol (Isovue 370) Non-Ionic Low Osmolar 580 320 Ionic Ioxaglate (Hexabrix) 2100 370 Ionic Metrizoate (Isopaque Coronar 370) High Osmolar 1550 300 Ionic Monomer Diatrizoate (Hypaque 50) Ionic Osmolality Iodine Content Type Name
  4. 4. Ionic Contrast Agents <ul><li>> 10 million diagnostic procedures / year </li></ul><ul><li>Conventional ionic contrast reactions - 10% </li></ul><ul><li>1 in 1000 severe </li></ul><ul><li>Contrast Myths </li></ul><ul><li>not caused by iodine </li></ul><ul><li>not related to shellfish </li></ul><ul><li>not true allergy (no drug-antibody) </li></ul><ul><li>mechanism remains unknown </li></ul>
  5. 5. Anaphylactoid (idiosyncratic) <ul><li>unpredictable </li></ul><ul><li>dose independent </li></ul><ul><li>prevalence 1-2% (0.04 - 0.22% severe) </li></ul><ul><li>fatal 1 in 75,000 </li></ul>
  6. 6. Chemotoxic <ul><li>predictable </li></ul><ul><li>dose dependent </li></ul><ul><li>due to osmolality or ionic composition </li></ul><ul><li>Nonionic vs Ionic </li></ul><ul><li>Contrast reactions decreased 5 fold </li></ul><ul><li>Fatalities unchanged </li></ul>
  7. 7. Risk Factors <ul><li>Previous contrast reaction either moderate or severe </li></ul><ul><ul><li>asthma </li></ul></ul><ul><ul><li>allergy history requiring medical treatment </li></ul></ul><ul><ul><li>pretesting poor predictor of reaction </li></ul></ul><ul><li>Repeat Reactions, ionic </li></ul><ul><ul><li>bronchospasm 40% to facial edema 70% </li></ul></ul><ul><ul><li>decrease to 6 - 9% with pretreatment </li></ul></ul><ul><ul><li>decrease to 0.6% with pretreatment and switch to nonionic </li></ul></ul>
  8. 8. Late Reactions <ul><li>1 hr to 1 week following contrast injection </li></ul><ul><li>Headache, myalgias, fever, skin reactions </li></ul><ul><li>Risk Factors </li></ul><ul><ul><li>Previous contrast reaction </li></ul></ul><ul><ul><li>Interleukin-2 treatment </li></ul></ul><ul><li>usually self-limited, treat severe reactions with steroids </li></ul>
  9. 9. Severity of Reactions - Minor <ul><li>Nausea & vomiting </li></ul><ul><li>Urticaria </li></ul><ul><li>Pruritis </li></ul><ul><li>Diaphoresis </li></ul>
  10. 10. Severity of Reactions - Moderate <ul><li>Faintness </li></ul><ul><li>Facial edema </li></ul><ul><li>Laryngeal edema </li></ul><ul><li>Bronchospasm </li></ul>
  11. 11. Severity of Reactions - Severe <ul><li>Pulmonary edema </li></ul><ul><li>Respiratory arrest </li></ul><ul><li>Cardiac arrest </li></ul><ul><li>Seizures </li></ul>
  12. 12. Renal Toxicity (increased serum creatinine by more than 25% or > 0.5 mg%) <ul><li>2-7% </li></ul><ul><li>Risk Factors </li></ul><ul><ul><li>5 - 10 fold increase with pre-existing renal insufficiency (increased creatinine) </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>CHF </li></ul></ul><ul><ul><li>Age > 70 </li></ul></ul><ul><ul><li>Taking nephrotoxic drugs (nonsteroidal inflammatory agents, gentomycin etc.) </li></ul></ul>
  13. 13. Renal Toxicity (increased serum creatinine by more than 25% or > 0.5 mg%) <ul><li>direct relationship between serum creatinine and likelihood nephrotoxicity </li></ul><ul><li>Hydrate 100 ml/hr Normal saline 4 hrs prior to procedure, continue for 24 hours </li></ul><ul><li>Those on hemodialysis do not need extra sessions or dialysis immediately following contrast administration </li></ul>
  14. 14. Metformin (Glucophage) <ul><li>oral diabetic agent </li></ul><ul><li>patients with renal insufficiency may develop lactic acidosis </li></ul><ul><li>withhold drug for 48 hrs after contrast administration in all patients taking this drug </li></ul>
  15. 15. Screening Creatinine <ul><li>Which patients need screening creatinine? Consider if patient has one of the following risk factors: </li></ul><ul><ul><li>Known renal insufficiency </li></ul></ul><ul><ul><li>Diabetes mellitus </li></ul></ul><ul><ul><li>Lasix or nephrotoxic drugs </li></ul></ul><ul><ul><li>Solitary kidney </li></ul></ul>
  16. 16. Treatment Contrast Reactions <ul><li>Nausea & Vomiting </li></ul><ul><ul><li>usually self-limited </li></ul></ul><ul><ul><li>protracted: Prochlorperazine (Compazine) 5-10 mg IM </li></ul></ul><ul><li>Urticaria </li></ul><ul><ul><li>Diphenhydramine (Benadryl) 25 - 50 mg IM, caution: drowsiness </li></ul></ul><ul><ul><li>add Cimetidine (Tagamet) 300 mg in 20 ml, IV slowly </li></ul></ul>
  17. 17. Treatment Contrast Reactions <ul><li>Hypotension </li></ul><ul><li>Bradycardia (Vasovagal) </li></ul><ul><ul><li>elevate legs (infuses 700 ml) </li></ul></ul><ul><ul><li>IV fluid (normal saline) </li></ul></ul><ul><ul><li>O2 3 L/min </li></ul></ul><ul><ul><li>atropine 0.6 mg IV push, repeat up to 3 mg total </li></ul></ul><ul><li>Tachycardia </li></ul><ul><ul><li>elevate legs </li></ul></ul><ul><ul><li>IV fluid (normal saline) may require > 1 Liter </li></ul></ul><ul><ul><li>O2 3 L/min </li></ul></ul>
  18. 18. Treatment Contrast Reactions <ul><li>Bronchospasm or laryngeal edema </li></ul><ul><ul><li>O2 3 L/min </li></ul></ul><ul><ul><li>Epinephrine 1:1000 (0.1 - 0.2 ml subq) or 1:10,000 1 ml IV over 3 min </li></ul></ul><ul><ul><li>Beta 2 agonist 2 -3 puffs </li></ul></ul><ul><ul><ul><li>albuterol (Proventyl) </li></ul></ul></ul><ul><ul><ul><li>metaproterenol (Alupent) </li></ul></ul></ul><ul><ul><ul><li>terbutaline (Brethaine) </li></ul></ul></ul>
  19. 19. Treatment Contrast Reactions <ul><li>Anaphylactoid </li></ul><ul><li>O2 3 L/min </li></ul><ul><li>IV normal saline </li></ul><ul><li>Epinephrine </li></ul><ul><li>Benadryl 25 - 50 mg IV </li></ul><ul><li>Tagamet 300 mg in 20 ml IV slowly </li></ul><ul><li>Solu-medrol 1 gm IV </li></ul><ul><ul><li>Note: if patient taking beta blocker </li></ul></ul><ul><ul><li>glucagon 1 - 5 mg IV bolus followed by infusion 5-15 ug/min or </li></ul></ul><ul><ul><li>isoproternol 1:5000 (0.2 mg/ml) </li></ul></ul><ul><ul><ul><li>IV 0.5 - 1.0 ml diluted in 10 ml </li></ul></ul></ul><ul><ul><ul><li>1 mg increments </li></ul></ul></ul>
  20. 20. Treatment Contrast Reactions <ul><li>Seizures </li></ul><ul><ul><li>protect airway </li></ul></ul><ul><ul><li>Diazepam (valium) 5 mg IV slowly </li></ul></ul><ul><li>Suspected pheochromocytoma </li></ul><ul><ul><li>phentolamine (Regitine) 5.0 ml (5 mg) IV bolus </li></ul></ul><ul><li>Pregnancy </li></ul><ul><ul><li>Discard breast milk for 24 hours following contrast administration </li></ul></ul>
  21. 21. Extravasation <ul><li>Elevate extremity </li></ul><ul><li>Ice pack 3x day </li></ul><ul><li>Observe for 2-4 hours if volume > 5ml </li></ul>
  22. 22. Extravasation <ul><li>Plastic Surgery Consultation </li></ul><ul><li>ionic > 30 ml </li></ul><ul><li>nonionic > 100 ml </li></ul><ul><li>skin blistering/significant tissue damage </li></ul><ul><li>altered tissue perfusion </li></ul><ul><li>increasing pain after 2-4 hours </li></ul><ul><li>change in sensation distal to site of extravasation </li></ul>
  23. 23. Pretreatment Protocols <ul><li>Reduces minor reactions </li></ul><ul><li>Benadryl 50 mg IM or PO 1 hr before procedure </li></ul><ul><li>Prednisone 50 mg PO 13, 7, 1 hr before procedure </li></ul><ul><li>Observe patient at least 30 minutes following injection </li></ul>
  24. 24. Pretreatment Protocols <ul><li>Reduction of Nephrotoxicity </li></ul><ul><ul><li>Creatinine level > 2 mg/dl </li></ul></ul><ul><ul><li>Hydrate patient - Oral fluids if unable to drink use IV saline </li></ul></ul><ul><ul><li>Mild Renal Insufficiency Patients – add N-acetyl-cysteine (Mucomyst) : 600 or 1,200 mg PO BID the day before and day of the procedure or 150 mg/kg IV over .5 hr or 50 mg/kg IV over 4 hr </li></ul></ul>
  25. 25. Risk of Nephropathy <ul><li>A recent meta analysis: Radiology: Volume 239: May 2006 p.392-397: Drs Rao & Newhouse </li></ul><ul><li>Properly controlled clinical studies of IV administered radiographic contrast media fail to demonstrate renal damage. </li></ul>
  26. 26. ACR Manual on Contrast Media <ul><li>guide for radiologists in the use of iodinated contrast media </li></ul><ul><li>h ttp:// www.acr.org/s_acr/sec.asp?CID =2131&DID=16687 </li></ul>
  27. 27. References of Interest <ul><li>Guidelines for Contrast Media from the European Society of Urogenial Radiology: AJR:181, December 2003 p. 1463 – 1471. </li></ul><ul><li>Minimizing Adverse Reactions to Contrast Agents: Radiology Rounds, Massachusetts General Hospital, Volume 1, Issue 5 Oct 2003. </li></ul>

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