Various forms of contrast media have been used to improve medical imaging. • Their value has long been recognized, as attested to by their common daily use in imaging departments worldwide. • Like all other pharmaceuticals, however, these agents are not completely devoid of risk. • Adverse side effects from the administration of contrast media vary from minor physiological disturbances to rare severe life-threatening situations. • Preparation for prompt treatment of contrast media reactions must include preparation for the entire spectrum of potential adverse events and include prearranged response planning with availability of appropriately trained personnel, equipment, and medications. • Thorough familiarity with the presentation and emergency treatment of contrast media reactions must be part of the environment in which all intravascular contrast media are administered.

1. BY
GHULAM HUSSAIN
(CHQP(Pak) - RT(R) (CT) (MR
DAIGONOSTIC CONTRAST
REACTIONS & MANAGMENT

2. INTRODACTION
Various forms of contrast media have been used to improve medical imaging.
• Their value has long been recognized, as attested to by their common daily use
in imaging departments worldwide.
• Like all other pharmaceuticals, however, these agents are not completely devoid
of risk.
• Adverse side effects from the administration of contrast media vary from minor
physiological disturbances to rare severe life-threatening situations.
• Preparation for prompt treatment of contrast media reactions must include
preparation for the entire spectrum of potential adverse events and include
prearranged response planning with availability of appropriately trained
personnel, equipment, and medications.
• Thorough familiarity with the presentation and emergency treatment of
contrast media reactions must be part of the environment in which all
intravascular contrast media are administered.

3. As would be appropriate with any diagnostic procedure, preliminary
considerations for the
referring physician and the radiologist include:
1. Assessment of patient risk versus potential benefit of the contrast assisted
examination.
2. Imaging alternatives that would provide the same or better diagnostic
information.
3. Assurance of a valid clinical indication for each contrast medium
administration.
Because of the documented low incidence of adverse events, intravenous
injection of
contrast media may be exempted from the need for informed consent, but
this decision
should be based on state law, institutional policy, and departmental policy.

4. The approach to patients about to undergo a contrast-enhanced examination has three
general goals:
1) to assure that the administration of contrast is appropriate for the patient and the
indication;
2) to minimize the likelihood of a contrast reaction; and
3) to be fully prepared to treat a reaction should one occur
Achieving these aims depends on :
• obtaining an appropriate and adequate history for each patient,
• preparing the patient appropriately for the examination,
• having equipment available to treat reactions, and
• ensuring that expertise sufficient to treat even the most severe reactions is readily at
hand.
Although mild reactions to contrast media are relatively common, they are almost invariably
self-limited and of no consequence.
Severe, life threatening reactions, although rare, can occur in the absence of any specific
risk factors with any type of media.

5. RISK FACTORS FOR ADVERSE
REACTIONS
• Previous contrast reaction
• Type of contrast agent
• Allergy
• Asthma
• Renal insufficiency
• Cardiovascular disease
• Diabetes
• Anxiety
• Multiple myeloma
• Beta-blockers
• Sickle cell disease
• Age
• Concomitant use of intra-arterial medications like papavarine
• Pheochromocytoma
• Hyperthyroidism
• Myasthenia Gravis

7. IDIOSYNCRATIC REACTIONS
Definition :
unpredictable reactions which occur within 1 hour
of contrast medium administration and which are
unrelated to the dose of the contrast medium
above a certain level.
• Serious and most dreaded
• Occur without warning
• Cannot be reliably predicted

11. INITIAL APPROACH – ABC of Critical care
A – Airway
B – Breathing
C – Circulation
Call for help immediately while
resuscitating – do not hesitate

12. Management of moderate reactions
1. URTICARIA
Urticaria, also known as hives, is an outbreak of swollen, pale red
bumps or plaques (wheals) on the skin that appear suddenly -- either
as a result of the body's reaction to certain allergens, or for unknown
reasons.
• Discontinue the injection if not
completed
• No Rx in most cases
• H1-receptor blocker:
Diphenhydramine IV/IM/PO 25-50
mg
• Severe or widely disseminated
urticaria –Adrenaline (1:1000) 0.1-
0.3 ml SC (if no contraindications)

13. Management of moderate reactions
2. Facial or laryngeal edema
Oxygen @6-10 L/min (by
mask)
• Adrenaline SC or IM 0.1-
0.3 ml of 1:1000
• If Hypotension is present
– Adrenaline 3 ml of
1:10000 IV preferably
under ECG monitoring
• If not responsive – can be
repeated upto 1 mg
• Always seek appropriate
assisstance in nonresponsive
cases

14. Management of moderate reactions
3. Bronchospasm
• Oxygen 6-10L/min (mask)
• ECG, Saturation, BP
• Beta-agonist inhalers
(bronchodilators : terbutaline,
albuterol, metaproterenol) 2-3 puffs:
repeat as necessary
• IV/IM/SC adrenaline if not
responding
• IM/SC : 0.1-0.3 ml (1:1000)
• If hypotension – IV slow 1-3 ml (
1:10000) under ECG monitoring
• Max dose upto 1 mg
• Assistance must be sought in case of
non-responders and if SPO2 <88%

15. Management of Severe Reactions
1. Hypotension with tachycardia
• Legs elevated or Trendelenberg position
• ECG, Saturation, BP
• Oxygen @6-10 L/min (mask)
• Rapid IV fluids [ Ringer Lactate/NS)
• If poorly responsive, IV Adrenaline
1:10000 1 ml up to max 1 mg dose
• Appropriate assistance must be sought

16. 2. Hypotension with Bradycardia (Vagal
reaction)
• Secure airway. Oxygen 6-10 L/min
• Monitor vitals
• Raise Legs >60 deg or Trendelenberg
position
• IV fluids : Ringer lactate/NS
• Atropine 0.6-1 mg IV slow , max dose
Upto 0.04mg/kg (2-3 mg) in adult
• Complete resolution of bradycardia and
hypotension before discharge

17. 3. Hypertension (severe)
Oxygen @ 6-10 L/min (mask)
Monitor ECG, Saturation, BP
Nitroglycerine 0.4 mg Tab, Sublingual ( may repeat x 3 times) or,
topical 2%
ointment, apply 1-inch strip
If not responsive, then Labetalol 20 mg IV stat, F/B 20-80 mg IV every
10 minutes
upto a maximum of 300 mg.
Shift to ICU or emergency medicine department
For Pheochromocytoma – Phentolamine 5 mg IV . (may use Labetolol if
Phentolamine is not available)

18. 4. Seizures
• Oxygen @ 6-10 ml/min (mask)
• Diazepam 5 mg IV ( or more as appropriate) or midazolam
0.5 – 1 mg IV
• Phenytoin 15-18 mg/kg @ 50 mg/min for longer effect –
after physician
consultation.
• Benzodiazepines may cause respiratory depression – close
monitoring of vitals is
necessary
• Appropriate assistance must be sought

19. 5. Pulmonary edema
• Oxygen @ 6-10 ml/min (mask)
• Elevate torso
• IV diuretic – furosemide 20-40 mg IV slow
• Consider morphine (1-3 mg IV).
• Shift to ICU or Emergency medicine
department

20. Non-Idiosyncratic reactions
Definition : These are dose related reactions and depend upon the physiochemical
properties of the contrast medium, i.e. chemical composiion,
Osmolality and concentration of the injected contrast and also on the volume,
speed and multiplicity of the injection.
Reactions unrelated to contrast media :
• Pyrogenic
• Vasovagal
• Excessive dehydration
• Hypertensive crisis in pheochromocytoma
• Hypoglycemia
Chemotoxic
• Cardiovascular
• Neurologic
• Renal

21. Hyperosmolar reactions :
Due to very high osmolarity of HOCMs –
erythrocyte damage, BBB damage, endothelial
damage, vaodalitation,
hypervolemia and cardiac depression.

22. CONTRAST EXTRAVASATION
• It refers to the escape of the contrast material from the vessel in which it is
introduced, into the surrounding tissue or body cavity
• 0.1-0.9% of contrast injections
• Risk factors :
Atherosclerosis, PVD, Diabetes, Raynaud’s disease, Venous
thrombosis, prior radiation, extensive surgery, severely ill and deblitated,
indwelling lines > 24 hrs, multiple injections in onto same vein.
• Clinical features :
Mild – edema, erythema, stinging, tenderness
Severe – Compartment syndrome, ulcers, necrosis
• Prevention is better than cure – ensure properly secured IV access, extravasation
detectors
• Treatment – depends on the volume of extravasation

23. Management of Contrast extravasation