Imaging Pearls ❯ Contrast ❯ Complications of Contrast Injection
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- “A critical step in preventing significant extravasation is direct monitoring of the venipuncture site by palpation during the initial portion of the contrast medium injection. If no problem is encountered during the first 15 seconds, the individual monitoring the injection exits the CT scan room before the scanning begins. If extravasation is detected, the injection is stopped immediately. Communication between the technologist and the patient via an intercom or television system should be maintained throughout the examination.”
ACR Manual on Contrast Media
Version 9 (2013) - “Treatment of venous air embolism includes administration of 100% oxygen and placing the patient in the left lateral decubitus position (i.e., left side down). Hyperbaric oxygen has been recommended to reduce the size of air bubbles, helping to restore circulation and oxygenation. If cardio-pulmonary arrest occurs, closed-chest cardiopulmonary resuscitation should be initiated immediately.”
ACR Manual on Contrast Media
Version 9 (2013) - “Surgical consultation prior to discharge should be obtained whenever there is concern for a severe extravasation injury. An immediate surgical consultation is indicated for any patient in whom one or more of the following signs or symptoms develops: progressive swelling or pain, altered tissue perfusion “as evidenced by decreased capillary refill at any time after the extravasation has occurred, change in sensation in the affected limb, and skin ulceration or blistering. It is important to note that initial symptoms of a compartment syndrome may be relatively mild (such as limited to the development of focal paresthesia).”
ACR Manual on Contrast Media
Version 9 (2013) - “Because contrast media are designated as medications, the warming of contrast media has fallen under the regulation of The Joint Commission, which mandates that if contrast media are to be extrinsically warmed, there must be both a daily temperature log for each warmer and evidence of regular maintenance for the warming device(s). This regulation has led some institutions to reconsider the use of these warming devices and reevaluate whether warming iodinated contrast media to human body temperature has a significant practical, rather than just a theoretical, benefit for IV LOCM administration. Although some institutions have discontinued the routine use of contrast media warmers for low-rate (<5 mL/second), non-angiographic, non-cardiac applications, there are little published data investigating what effect this may have on patient adverse events.”
ACR Manual on Contrast Media
Version 9 (2013)
- Does faster injection rates result in higher extravasation rates?
- Potential factors
- Contrast injection rate (cc/sec)
- Contrast volume (cc)
- Contrast type (Omnipaque vs Visipaque)
- Gauge of needle (18 vs 20 vs 24)
- Type of needle (fenestrated or not) - “Automated IV contrast injection applying high flow rates (i.e., up to 8 mL/s) is performed without increased risk of extravasation. The overall extravasation rate was 1.2% and showed no correlation with iodine concentration, flow rates, or contrast material reactions. Performing high flow rates with low-diameter IV catheters (e.g., 22-gauge catheters) and a location of IV catheter in the hand is associated with a higher extravasation rate.”
Prospective study of access site complications of automated contrast injection with peripheral venous access in MDCT.
Wienbeck S et al.
AJR Am J Roentgenol. 2010 Oct;195(4):825-9 - “ Performing high flow rates with low-diameter IV catheters (e.g., 22-gauge catheters) and a location of IV catheter in the hand is associated with a higher extravasation rate.”
Prospective study of access site complications of automated contrast injection with peripheral venous access in MDCT.
Wienbeck S et al.
AJR Am J Roentgenol. 2010 Oct;195(4):825-9 - “The extravasation rate was highest with 22-gauge IV catheters (2.2%; p < 0.05) independently of the anatomic location. For 20-gauge IV catheters, extravasation rates were significantly higher in the dorsum of the hand than in the antecubital fossa (1.8% vs 0.8%; p = 0.018). Extravasation rates were higher in older patients (? 50 vs < 50 years, 0.6% vs 1.4%; p = 0.019).”
Prospective study of access site complications of automated contrast injection with peripheral venous access in MDCT.
Wienbeck S et al.
AJR Am J Roentgenol. 2010 Oct;195(4):825-9 - IV Contrast Extravasation Management
- What do you do?
- Who do you call?
- What are key parameters in patient management?
- When do you need to call plastic surgery (or a surgeon)? - “ Extravasation of CT scan contrast media into upper extremity subcutaneous tissue is a relatively frequent complication of injection. Potential sequelae of extravasation include compartment syndrome, skin sloughing, and necrosis. Many institutions institute protocols requiring inpatient plastic surgery consultations immediately following extravasation injury to the upper extremity. We hypothesize that conversion to non-ionic contrast media for contrast CT studies has greatly reduced the incidence of severe extravasation injuries, and may alleviate the need for routine hand surgery consultations.”
CT contrast extravasation in the upper extremity: strategies for management.
Sbitany H et al.
Int J Surg. 2010;8(5):384-6. - “Extravasation of non-ionic CT contrast media appears to be innocuous and can be treated with conservative therapy. Plastic surgery consultation should be obtained when there are obvious signs of skin and soft tissue compromise or symptoms of compartment syndrome.”
CT contrast extravasation in the upper extremity: strategies for management.
Sbitany H et al.
Int J Surg. 2010;8(5):384-6. - “In 102 consecutive cases, immediate surgical therapy was necessary in 0. Non-ionic medium was used in 94% of these cases, and ionic dye was used in 6%. Extravasation of less than 100 cc occurred in 90%, and only 10% were greater. Plastic surgery consultation was immediately obtained in 42% of cases. Factors prompting consultation included extravasation >30 cc, and the presence of erythema or induration. Trends for consultation remained without discernable pattern when patients were stratified by age, amount of extravasate, or anatomic location. Conservative management was recommended in all cases.”
CT contrast extravasation in the upper extremity: strategies for management.
Sbitany H et al.
Int J Surg. 2010;8(5):384-6. - ESUR Guidelines on Contrast Media
- Conservative management is adequate in most cases
- limb elevation
- apply ice packs
- careful monitoring
- If a serious injury is suspected, seek the advice of a surgeon. - ESUR Guidelines on Contrast Media
- This publication by the ESUR is well done and similar in many ways to the ACR 9.0 manual
- Well worth reading
- http://www.esur.org/guidelines/ - “ For soft-tissue extravasation of IV contrast media, 95% elevate the affected extremity, 76% use ice and 45% use heat.”
Practice Patterns for the Use of Iodinated IV Contrast Media for Pediatric CT Studies: A Survey of the Society for Pediatric Radiology
Callahan MJ et a.
AJR 2014;202:872-879 - “ Ninety five percent of our responders elevate the affected extremity after soft tissue extravasation, which decreases capillary hydrostatic pressure and promotes resorption. There is no clear evidence to favor the use of ice or heat compresses.”
Practice Patterns for the Use of Iodinated IV Contrast Media for Pediatric CT Studies: A Survey of the Society for Pediatric Radiology
Callahan MJ et a.
AJR 2014;202:872-879
- “ There is little evidence that ingestion of clear inert fluid prior to contrast enhanced CT is a cause of aspiration pneumonia; the length of fasting is varible in any country, being much longer in some hospitals than in others.”
Preparative Fasting for Contrast-enhanced CT:Reconsideration
Lee BY et al.
Radiology 2012; 263:444-450 - “ Currently the length of preparatory solid food fasting is variable in different medical centers, ranging from 0 hours to overnight.”
Preparative Fasting for Contrast-enhanced CT:Reconsideration
Lee BY et al.
Radiology 2012; 263:444-450
"Another risk factor for an extravasation was patient’s age. Significantly higher extravasation rates were observed for patients older than 50 years, a finging that is possibly explained by the more fragile veins of older patients, which increase the likelihood of extravasation."
Prospective Study of Access Site Complications of Automated Contrast InjectionWith Peripheral Venous Access in MDCT
Wienbeck S et al.
AJR 2010; 195:825-829"Performing high flow rates with low diameter catheters (e.g. 22-guage catheters) and a location of IV catheter in the hand is associated with a higher extravasation rate."
Prospective Study of Access Site Complications of Automated Contrast InjectionWith Peripheral Venous Access in MDCT
Wienbeck S et al.
AJR 2010; 195:825-829"Automated IV contrast injection applying highflow rates (i.e. up to 8 mL/s) is performed without increased risk of extravasation. The overall extravasation rate was 1.2% and showed no correlation with iodine concentration, flow rates, or contrast material reactions. Performing high flow rates with low diameter catheters (e.g. 22-guage catheters) and a location of IV catheter in the hand is associated with a higher extravasation rate."
Prospective Study of Access Site Complications of Automated Contrast InjectionWith Peripheral Venous Access in MDCT
Wienbeck S et al.
AJR 2010; 195:825-829- "In a single institution, extravasation of contrast material into the subcutaneous tissues occurred during attempted intravenous injection in less than 1% of patients,often involved large volumes of contrast material (50-150 ml) and nearly always resolved with conservative management."
Frequency, Management, and Outcome of Extravasation of Nonionic Iodinated Contrast Medium in 69,657 Intravenous Injections
Wang CL et al.
Radiology 2007; 243:80-87 - "The use of power injectors through 18- to 24-guage angiocatheters in children is safe when meticulous technique is used and personnel are appropriately trained. Our study showed a similar rate of extravasation as has been reported in other studies."
Safety of Power Injector Use in Children as Measured by Incidence of Extravasation
Amaral JG et al.
AJR 2006; 187:580-583