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Contrast: IV Contrast Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Contrast ❯ IV Contrast

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  •  ”Results: A total of five studies, including 307,329 CM injections (86,676 at room temperature and 220,653 warmed to 37 ◦C), were included in the analysis. For high viscosity CM, pre-warming was associated with significantly lower allergic reaction rates (OR: 0.59, 95% CI: 0.49–0.72, P < 0.00001). There was no significant difference in rates of extravasation for high viscosity CM (OR: 0.53, 95% CI: 0.20–1.43, P = 0.21). Discussion: Our meta-analysis suggests that warming CM to 37 ◦C is a safe and effective approach to reduce the risk of allergic reactions and physiologic reactions during injection of high-viscosity CM. However, there was no significant difference in extravasation rates between warmed and room temperature CM, regardless of viscosity.”  
    The relationship between iodinated contrast material temperature and adverse reactions: A meta-analysis of 307,329 injections  
    Mohamad Nawras et al.
    Clinical Imaging 100 (2023) 54–59
  • “Overall, our meta-analysis suggests that warming CM to 37 ◦C is a safe and effective approach to reduce the risk of allergic reactions and physiologic reactions during injection of high-viscosity CM. Furthermore, we demonstrate that pre-warming of low-viscosity CM is not necessary as it does not significantly reduce allergic reactions, extravasations, or physiologic reactions. Despite this, due to the limited number of studies, more extensive randomized controlled trials are necessary to validate our findings.”  
    The relationship between iodinated contrast material temperature and adverse reactions: A meta-analysis of 307,329 injections 
    Mohamad Nawras et al.
    Clinical Imaging 100 (2023) 54–59
  • IMPORTANCE Intravenous (IV) contrast medium is sometimes withheld due to risk of complication or lack of availability in patients undergoing computed tomography (CT) for abdominal pain. The risk from withholding contrast medium is understudied.
    OBJECTIVE To determine the diagnostic accuracy of unenhanced abdominopelvic CT using contemporaneous contrast-enhanced CT as the reference standard in emergency department (ED) patients with acute abdominal pain.
    CONCLUSION Unenhanced CT was approximately 30% less accurate than contrast-enhanced CT for evaluating abdominal pain in the ED. This should be balanced with the risk of administering contrast material to patients with risk factors for kidney injury or hypersensitivity reaction.
    Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Painin the Emergency Department
    Hiram Shaish et al
    JAMA Surg. 2023;158(7):e231112. 
  • “Unenhanced CT was approximately 30% less accurate than contrast-enhanced CT for evaluating abdominal pain in the ED. This should be balanced with the risk of administering contrast material to patients with risk factors for kidney injury or hypersensitivity reaction.”
    Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Painin the Emergency Department
    Hiram Shaish et al
    JAMA Surg. 2023;158(7):e231112. 
  • Key Points
    Question What is the diagnostic accuracy of unenhanced computed tomography (CT) in patients admitted to an emergency department with abdominal pain?
    Findings In this multicenter diagnostic accuracy study, unenhanced CT was approximately 30 percentage points less accurate than contrast-enhanced CT for diagnosing the cause of pain and identifying actionable secondary diagnoses.
    Meaning In a general population of emergency department patients with abdominal pain, using unenhanced CT to avoid risks of intravenous contrast medium administration was associated with a large diagnostic penalty.
    Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Painin the Emergency Department
    Hiram Shaish et al
    JAMA Surg. 2023;158(7):e231112. 
  • “False-negative (faculty, 13% to 19%; residents, 15%to 27%) and false-positive (faculty, 10% to 21%; residents, 8%to 19%) results were common at unenhanced CT for all radiologists. This likely was because reduced image contrast reduces accuracy and radiologist confidence. Example false-positive results included pancreatitis, bowel perforation, diverticulitis, pyelonephritis, and neoplasm. Example false-negative results included vascular dissection, hemoperitoneum, infection, and neoplasm. The commonality of both false-positive and false-negative results challenges efforts to adjust reading style to reduce error. In other words, the diagnostic penalty resulting from the elimination of contrast medium is not easily fixable by simply raising or lowering the threshold to report a diagnosis.”
    Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Painin the Emergency Department
    Hiram Shaish et al
    JAMA Surg. 2023;158(7):e231112. 
  • “We intentionally sampled a general population of ED patients with abdominal pain because dozens of diagnoses are commonly made with contrast-enhanced CT in that setting. Restricting the cohort to a specific diagnosis would have inflated the diagnostic accuracy. We subtracted oral, as well as IV, contrast medium from the reference standard to generate the unenhanced CT data. Diagnostic accuracy might have been higher had oral contrast medium been visible, or different had a single-energy unenhanced CT been used.”
    Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Painin the Emergency Department
    Hiram Shaish et al
    JAMA Surg. 2023;158(7):e231112. 
  • “In summary, unenhanced CT was approximately 30 percentage points less accurate than contrast- enhanced CT for the evaluation of abdominal pain in the ED. Prior studies evaluating unenhanced CT in this population likely have overstated its accuracy due to focus on 1 or few diagnoses or lack of a robust reference standard. The consistent results we observed across 3 centers suggest that the substantial diagnostic penalty we observed is likely to be related to the removal of contrast medium rather than to radiologist idiosyncrasy. For patients with risk factors for receiving iodinated contrast medium (eg, prior hypersensitivity reaction, severe kidney disease) or for patients receiving care in locations where contrast media is in short supply, the diagnostic risk of withholding contrast medium should be considered in the risk-benefit analysis. In many patients, the risk of with holding iodinated contrast medium may be higher than the risk of administering it.
    Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Pain in the Emergency Department
    Hiram Shaish et al
    JAMA Surg. 2023;158(7):e231112. 
  • “Adding IV contrast material provides the benefit of increased diagnostic accuracy at the cost of potential adverse reactions like contrast-induced nephropathy, extravasation, and/or allergic reaction. The risk of kidney injury varies based on pre-CT kidney function: it approaches 0% with normal kidney function but is higher with chronically impaired kidney function. The rate of contrast extravasation is low(0.7%), and most extravasation events result in minimal to no long-term adverse effects. In a series of 69 657 IV contrast injections, 1 patient experienced extravasation of 75 mL of contrast into the hand. The risk of immediate hypersensitivity reactions into nonionic low-osmolar iodinated contrast media is 0.2% to 3% and lower for severe reactions.”
    Intravenous Contrast in Computed Tomography Imaging for Acute Abdominal Pain
    D. Dante Yeh, MD, MHPE; Courtney C. Moreno, MD; Mayur B. Patel, MD
    JAMA Surgery July 2023 Volume 158, Number 7
  • “For otherwise healthy individuals, the risk of a 30% loss in diagnostic accuracy if IV contrast material is withheld should be weighed against the exceedingly low risk of an adverse event. For patients with impaired kidney function or a history of prior severe allergic reaction, the risk-benefit balance may warrant withholding IV contrast. On the other hand, there are some diagnoses that one cannot see without IV contrast like an intravascular thrombus.”
    Intravenous Contrast in Computed Tomography Imaging for Acute Abdominal Pain
    D. Dante Yeh, MD, MHPE; Courtney C. Moreno, MD; Mayur B. Patel, MD
    JAMA Surgery July 2023 Volume 158, Number 7
  • “When we choose a noncontrast approach, we should be intentionally accepting diagnostic uncertainty, although this is already well accepted for certain diseases. For example, for patients with acute-onset flank pain with a high pretest probability for urolithiasis, omitting IV contrast is usually appropriate. However, there will always be patients with chronic kidney disease and anaphylactic allergic reactions and perhaps another national shortage. In these scenarios, we must ask ourselves: how much added value does the IV contrast provide against the risk of a missed and actionable acute diagnosis? In the low-risk patient, complications of IV contrast is often negligible, and the benefits of routine IV contrast far outweigh the risks.”
    Intravenous Contrast in Computed Tomography Imaging for Acute Abdominal Pain
    D. Dante Yeh, MD, MHPE; Courtney C. Moreno, MD; Mayur B. Patel, MD
    JAMA Surgery July 2023 Volume 158, Number 7
  • Purpose: Intravenous iodinated contrast is a commonly used diagnostic aid to improve image quality on computed tomography. There exists a small risk of post-contrast acute kidney injury in patients receiving IV contrast. One of the biggest risk factors for developing PC-AKI is the presence of pre-existing renal dysfunction, making it important to measure the renal function prior to contrast administration. Point of care (POC) devices offer a quick estimation of renal function, potentially improving workflows in radiology departments.  
    Conclusion: POC devices are moderately accurate at detecting renal impairment in patients undergoing radiological investigations. They seem to be a good screening tool; however, any low eGFR values should be further examined.
    Is point of care renal function testing reliable screening pre-IV contrast administration?  
    Namit Mathur et al.
    Emergency Radiology (2021) 28:77–82 
  • “A key factor in the development of PC-AKI is the presence of pre-existing chronic kidney disease (CKD) . Hence, it is essential to estimate the patient’s renal function prior to intravenous iodinated contrast administration. CKD is classified according the patient’s eGFR. The Royal Australian and New Zealand College of Radiologists (RANZCR) iodinated contrast guidelines stratify renal function into three groups. Patients with an eGFR of less than 30 are classified as having severe renal impairment; these patients require a discussion with the referring clinician to weigh up the risks versus bene- fits of contrast administration and require periprocedural hy- dration. Additionally, patients with a rapidly changing renal function with an eGFR between 30 and 45 may also benefit from periprocedural hydration.”
    Is point of care renal function testing reliable screening pre-IV contrast administration?  
    Namit Mathur et al.
    Emergency Radiology (2021) 28:77–82 
  • “Point of care devices are moderately accurate for identification of renally impaired patients prior to intravenous contrast ad- ministration for CT examination. The results of Abbott iSTAT device show better correlation with laboratory results than the Nova StatSensor device. Within the limits of small number of high risk patients in this study, both devices seem to be accu- rate in diagnosing high-risk patients with an eGFR of less than 30. They become moderately accurate at higher eGFRs. POC devices can be implemented as a screening tool prior to IV contrast administration as both machines have low false neg- ative rates. Caution should be taken when the POC eGFR values are discordant with previously known blood test result or contradictory to the answers on the pre-iodination contrast questionnaire/screening forms.”
    Is point of care renal function testing reliable screening pre-IV contrast administration?  
    Namit Mathur et al.
    Emergency Radiology (2021) 28:77–82 
  • “In conclusion, weight-based contrast dosing using injector software maintained or improved IV contrast enhancement and lesion depiction across patient sizes when using a minimum contrast volume of 110 mL (38.5 g of iodine). Total body weight and body surface area correlated well with the software selected contrast volumes, whereas BMI was a poor predictor of IV contrast volume needed to maintain contrast enhancement across patient sizes. Our study, which used WBD relative to our standard fixed-dosing approach, suggests that patients of above-average size present opportunities for lowering contrast usage, whereas certain patients of below-average size may benefit from an increased amount of contrast with WBD.”
    Comparison of Abdominal CT Enhancement and Organ Lesion Depiction Between Weight-Based Scanner Software Contrast Dosing and a Fixed-Dose Protocol in a Tertiary Care Oncologic Center
    Corey T. Jensen et al.
    J Comput Assist Tomogr. 2019 ; 43(1): 155–162
  • Background: There is little published evidence examining the use of contrast material (CM) and the risk of acute renal adverse events (AEs) in individuals with increasingly common risk factors including cancer and chronic kidney disease (CKD). The objective of this study was to use real world hospital data to test the hypothesis that inpatients with cancer having CT procedures with iodinated CM would have higher rates of acute renal AEs in comparison to inpatients without cancer.
    Risk of renal events following intravenous iodinated contrast material administration among inpatients admitted with cancer a retrospective hospital claims analysis
    Chaan S. Ng et al.
    Cancer Imaging (2018) 18:30
  • Methods: Inpatient hospital visits in the Premier Hospital Database from January 1, 2010 through September 30, 2015 were eligible for inclusion. The outcome of interest was a composite of acute renal AEs including: acute kidney injury, acute renal failure requiring dialysis, contrast induced-acute kidney injury and renal failure. Multivariable models, adjusted for differences in patient demographics and comorbid conditions, were used to estimate the incremental risk of acute renal AEs by CT (with or without iodinated CM), CKD stage and type of cancer.
    Results: Among 29,850,475 inpatient visits across 611 hospitals, 7.4% had record of a CT scan, 5.9% had CKD, and 3.4% had the primary diagnosis of cancer. The baseline risk for an acute renal AE in patients without cancer or CKD and no CT or CM was 0.5%. The absolute risk increases from baseline by 0.2% with a CT and by 0.8% with iodinated CM. Patients with CKD having a CT scan with iodinated CM have an absolute risk of 4.1 to 9.7% depending on the stage of CKD. For patients with cancer, the absolute risk increases, varying from 0.3 to 2.3% depending on the type of cancer.
    Risk of renal events following intravenous iodinated contrast material administration among inpatients admitted with cancer a retrospective hospital claims analysis
    Chaan S. Ng et al.
    Cancer Imaging (2018) 18:30
  • Conclusions: Inpatients with cancer are at higher likelihood of developing acute renal AEs following CT with iodinated CM compared to those without a cancer. Understanding the underlying risks of acute renal AEs among complex inpatient admissions is an important consideration in treatment choices for oncology patients.
    Risk of renal events following intravenous iodinated contrast material administration among inpatients admitted with cancer a retrospective hospital claims analysis
    Chaan S. Ng et al.
    Cancer Imaging (2018) 18:30
  • “The baseline risk for an acute renal event in patients without cancer or CKD and no CT or CM was 0.5%. When a CT procedure was performed with iodinated CM the risk increased to 1.5%. Patients with CKD having a CT with CM had an increased risk of an acute renal event from 2.5 to 8.1% depending on the stage of CKD. Among cancer patients, the overall risk increased from baseline by 0.9%. Risk increase from baseline by type of cancer ranged from 0.3 for endocrine and lung cancer to over 2% for leukemia and urinary cancer.”
    Risk of renal events following intravenous iodinated contrast material administration among inpatients admitted with cancer a retrospective hospital claims analysis
    Chaan S. Ng et al.
    Cancer Imaging (2018) 18:30
  • Purpose: This study was performed to measure the incidence and identify potential predictors of contrast-induced nephropathy (CIN) in cancer patients without chronic kidney disease and with normal or near-normal baseline serum creatinine measures who underwent contrast-enhanced computed tomography (CECT). Severity of CIN was reported based on the RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal disease) classification of acute kidney injury.
    Results: The incidence of CIN was 8.0%. Serial CT examination [odds ratio (OR) 4.09; 95% confidence interval (CI) 1.34-12.56], hypotension before the CT scan (OR 3.95; 95% CI 1.77-8.83), liver cirrhosis (OR 2.82; 95% CI 1.06-7.55), BUN/creatinine >20 (OR 2.54; 95% CI 1.44-4.46), and peritoneal carcinomatosis (OR 1.75; 95% CI 1.01-3.00) were independently associated with CIN. Of 66 CIN patients, 44 met any of the severity criteria of the RIFLE classification. Five of these patients died during hospitalization but only one death was related to renal failure.
    Contrast-induced nephropathy in patients with active cancer undergoing contrast-enhanced computed tomography
    Seok-In Hong et al.
    Support Care Cancer2016 Mar;24(3):1011-7.
  • Conclusions: Even when the baseline serum creatinine is ≤1.5 mg/dL, a significant portion of cancer patients are still at risk of CIN. Consecutive CECT examinations, hypotension before CT, liver cirrhosis, dehydration, and peritoneal carcinomatosis seem to predispose patients to CIN.
    Contrast-induced nephropathy in patients with active cancer undergoing contrast-enhanced computed tomography
    Seok-In Hong et al.
    Support Care Cancer 2016 Mar;24(3):1011-7.
  • "Remarkably, the risks of developing AKI are increased in the elderly, in patients with chronic kidney disease or diabetes, and with dehydration or administration of nephrotoxic chemotherapeutics. Given the common occurrence of post-contrast acute kidney injury (PC-AKI) in clinical practice, primary care physicians and all specialists involved in managing patients with cancer should be aware of the strategies to reduce the risk of this event.”
    Acute kidney injury from contrast- enhanced CT procedures in patients with cancer: white paper to highlight its clinical relevance and discuss applicable preventive strategies
    Cosmai L et al.
    ESMO Open 2020;5:e000618. doi:10.1136

  • Acute kidney injury from contrast- enhanced CT procedures in patients with cancer: white paper to highlight its clinical relevance and discuss applicable preventive strategies
    Cosmai L et al.
    ESMO Open 2020;5:e000618. doi:10.1136

  • Acute kidney injury from contrast- enhanced CT procedures in patients with cancer: white paper to highlight its clinical relevance and discuss applicable preventive strategies
    Cosmai L et al.
    ESMO Open 2020;5:e000618. doi:10.1136
  • AKI Prevention Strategies in the Oncology Patient
    - Overall, prehydration and the use of tailored dose of iodinated CM in patients at high risk are recommended.
    - A preventive strategy using saline prehydration, as well as the use of the CM with the lowest osmolarity, is highly advisable, particularly in high-risk patients.
    - Iso-osmolar contrast medium (IOCM) should thus be considered the first choice in this setting, particularly if patients with cancer present a high risk of developing AKI (eg, they present diabetes, liver diseases, hypertension, pre-existing CKD, low hematocrit, age over 70 years, cardiac diseases and recent myocardial infarction (<1 month)).
  • “Iso-osmolar contrast medium (IOCM) should thus be considered the first choice in this setting, particularly if patients with cancer present a high risk of developing AKI (eg, they present diabetes, liver diseases, hypertension, pre-existing CKD, low hematocrit, age over 70 years, cardiac diseases and recent myocardial infarction (<1 month)).”
    Acute kidney injury from contrast- enhanced CT procedures in patients with cancer: white paper to highlight its clinical relevance and discuss applicable preventive strategies
    Cosmai L et al.
    ESMO Open 2020;5:e000618. doi:10.1136
  • “AKI is a serious and frequent concern in patients with cancer who often present comorbidities or receive drugs that may increase the risk of developing this event. Therefore, it should be mandatory to try to prevent PC-AKI (as recently defined by Lencioni et al58) in patients with cancer at risk, with the implementation of dedicated protocols (an example, based on the experience of the authors, is presented in figure 1). In particular, prehydration and the choice of specific CM doses and classes (IOCM vs LOCM) in patients at high risk are recommended: a preventive strategy using saline prehydration, as well as the use of the CM with the lowest osmolarity, is highly advisable, particularly in high-risk patients. IOCM should thus be considered the first choice in this setting.”
    Acute kidney injury from contrast- enhanced CT procedures in patients with cancer: white paper to highlight its clinical relevance and discuss applicable preventive strategies
    Cosmai L et al.
    ESMO Open 2020;5:e000618. doi:10.1136
  • “Another key point to keep in mind is that, beyond cisplatin, a number of other anticancer agents (eg, targeted agents and immune checkpoint inhibitors) may induce glomerular injury, tubulopathies as well as interstitial nephritis. Thus, since almost all patients with cancer on active treatment undergo a number of CECT scans, the risk of an increased nephrotoxicity is particu- larly high, not to take into account the fact that patients on clinical trials usually undergo very closely repeated iodinated CM administration in order to monitor the activity of experimental treatments.”
    Acute kidney injury from contrast- enhanced CT procedures in patients with cancer: white paper to highlight its clinical relevance and discuss applicable preventive strategies
    Cosmai L et al.
    ESMO Open 2020;5:e000618. doi:10.1136
  • ►  The incidence of AKI in patients with cancer ranges from 12% to 17%, and it is higher than the incidence observed in patients with- out cancer (5–8%).
    ►  Risk factors include the type of cancer, comorbidities, cotreatment with other drugs (eg, furosemide, antibiotics, chemotherapy and iodinated CM administration).
    ►  Specific cancer locations (eg, kidney, liver, oesophagus, pancreas and uterus) and cancer types (lymphomas, leukaemias, mixed lymphosarcoma and multiple myeloma) have been linked with an increased risk of AKI.
    Acute kidney injury from contrast- enhanced CT procedures in patients with cancer: white paper to highlight its clinical relevance and discuss applicable preventive strategies
    Cosmai L et al.
    ESMO Open 2020;5:e000618. doi:10.1136
  • ►  Among commonly used anticancer agents (either cytotoxic chemo- therapeutics, targeted agents or immune checkpoint inhibitors), an increased risk of AKI has been documented particularly in patients treated with pemetrexed, ifosfamide, cisplatin, bevacizumab and cetuximab.
    ►  A short time span between chemotherapy administration and CM injection is associated with an increased risk of AKI. Closely repeated administrations of iodinated CM are associated with a higher risk of PC-AKI.
    Acute kidney injury from contrast- enhanced CT procedures in patients with cancer: white paper to highlight its clinical relevance and discuss applicable preventive strategies
    Cosmai L et al.
    ESMO Open 2020;5:e000618. doi:10.1136
  • AKI is a serious and frequent concern in patients with cancer who often present comorbidities or receive drugs that may increase the risk of developing this event. Therefore, it should be mandatory to try to prevent PC-AKI (as recently defined by Lencioni et al58) in patients with cancer at risk, with the implementation of dedicated protocols (an example, based on the experience of the authors, is presented in figure 1). In particular, prehydration and the choice of specific CM doses and classes (IOCM vs LOCM) in patients at high risk are recommended: a preventive strategy using saline prehydration, as well as the use of the CM with the lowest osmolarity, is highly advisable, particularly in high-risk patients. IOCM should thus be considered the first choice in this setting.”
    Acute kidney injury from contrast- enhanced CT procedures in patients with cancer: white paper to highlight its clinical relevance and discuss applicable preventive strategies
    Cosmai L et al.
    ESMO Open 2020;5:e000618. doi:10.1136
  • Other Issues with IV Contrast and the Oncology Patient
    - Vascular access
    - Frequency of extravasation
    - Need for higher injection rates for oncology staging/ followup protocols
  • Objective: The aim of this study was to evaluate the incidence of extravasation of iodinated contrast medium (ICM) at the site of intravenous injection in oncology patients submitted to computed tomography (CT).
    Materials and Methods: This was a retrospective, descriptive, single-center study that evaluated all patients who underwent CT with ICM administration and presented ICM extravasation, at a cancer center, between January 2010 and December 2015.
    Results: During the study period, we evaluated a total of 99,076 ICM injections and identified 199 cases of extravasation, the incidence rate therefore being 0.20%. Among the patients who presented extravasation, the mean age was 59.22 years and 60% were female. The extravasation was classified as mild in 94.10% of the patients and as moderate in 5.90%. There were no cases of severe extravasation in the sample.
    Conclusion: The incidence of ICM extravasation in cancer patients submitted to CT in the present study was similar to that reported for the general population, according to other studies in the literature. The vast majority of cases of extravasation were considered mild, and no severe cases were observed in the study sample.
    Extravasation of iodinated contrast medium in cancer patients undergoing computed tomography
    Hernandes Cerqueira de Souza Silva et al.
    Radiol Bras. 2018 Jul/Ago;51(4):236–241.
  • Conclusion: The incidence of ICM extravasation in cancer patients submitted to CT in the present study was similar to that reported for the general population, according to other studies in the literature. The vast majority of cases of extravasation were considered mild, and no severe cases were observed in the study sample.
    Extravasation of iodinated contrast medium in cancer patients undergoing computed tomography
    Hernandes Cerqueira de Souza Silva et al.
    Radiol Bras. 2018 Jul/Ago;51(4):236–241.
  • "Patients at risk for CIN should not be denied a contrast-enhanced CT examination if the benefit of the clinical information derived from the examination is considered to outweigh the risk of CIN. Nevertheless, screening of patients who are likely to be at risk for CIN and institution of precautionary measures when warranted are important components of optimal oncologic imaging practice.”
    Contrast safety in the cancer patient: preventing contrast-induced nephropathy
    Jay P. Heiken
    Cancer Imaging (2008) 8, S124-S127
  • OBJECTIVE. The purpose of our study was to assess the effect of IV contrast medium administered at CT on serum creatinine in an oncologic ICU population and to determine which of the variables before CT are most associated with renal function after administration of contrast material.
    CONCLUSION. Administration of IV contrast medium in oncologic ICU patients with relatively normal creatinine is associated with an increase in creatinine but not beyond that of simply undergoing CT or of a matched non-CT group in ICU. The eGFR, which includes sex in its derivation, may be a better predictor of contrast-enhanced renal function than creatinine.
    Effect of IV Contrast Medium on Renal Function in Oncologic Patients Undergoing CT in ICU
    Ng CS et al.
    AJR 2010; 195:414–422
  • “In summary, among oncologic patients in the ICU with relatively normal levels of creatinine, administering IV contrast medium during CT is associated with a rise in creatinine levels after CT but not beyond that of simply undergoing CT. Undergoing CT is itself associated with an increase in serum creatinine but not beyond that of similar patients in the ICU not undergoing CT. Factors associated with serum creatinine levels after IV contrast material appear to include severity of illness at the time of CT (as assessed by the nonrenal mSOFA score) and sex but not baseline creatinine at the time of CT or its precedent trend."
    Effect of IV Contrast Medium on Renal Function in Oncologic Patients Undergoing CT in ICU
    Ng CS et al.
    AJR 2010; 195:414–422
  • Objectives: To determine the incidence of post-contrast acute kidney injury (PC-AKI) and presumed contrast-induced acute kidney injury (CI-AKI) following contrast-enhanced CT (CECT) with intravenous application of a reduced dose of the iso-osmolar contrast agent iodixanol in cancer patients with chronic kidney disease.
    Methods: 198 oncology patients with a baseline estimated glomerular filtration rate (eGFR) <60ml/ min/1.73m2 undergoing a total of 237 CECTs using a reduced dose of 60ml iodixanol were retrospectively analyzed. Statistical analysis was performed for the entire cohort and sub- groups. The effect of additional risk factors on the occurrence of PC-AKI was evaluated.
    Results: The overall PC-AKI incidence was 6.3%. Excluding patients with concurrent medical conditions known to directly and independently impact kidney function and patients with AKI pre- ceding the CT-scan resulted in a presumed CI-AKI incidence of 3.8%. No permanent post- contrast worsening of renal function and no AKI treatment were required. Subgroups considering baseline eGFR yielded PC-AKI incidences of 4.6% (eGFR 45-60ml/min/1.73m2, n = 130), 7.4% (eGFR 30-45ml/min/1.73m2, n = 95) and 16.7% (eGFR <30ml/min/1.73m2, n = 12). Additional patient related risk factors did not show any significant effect on the occurrence of PC-AKI.
    Conclusions: Low incidences of PC-AKI/CI-AKI suggest that a reduced dose of an iso-osmolar contrast agent is safe in high-risk oncological patients with impaired renal function.
  • Objectives: To determine the incidence of post-contrast acute kidney injury (PC-AKI) and presumed contrast-induced acute kidney injury (CI-AKI) following contrast-enhanced CT (CECT) with intravenous application of a reduced dose of the iso-osmolar contrast agent iodixanol in cancer patients with chronic kidney disease.
    Conclusions: Low incidences of PC-AKI/CI-AKI suggest that a reduced dose of an iso-osmolar contrast agent is safe in high-risk oncological patients with impaired renal function.
    Incidence of contrast-induced acute kidney injury (CI-AKI) in high-risk oncology patients undergoing contrast-enhanced CT with a reduced dose of the iso-osmolar iodinated contrast medium iodixanol
    Sebastian Werner et al.
    PLoS ONE 15(5): e0233433. May 2020
  • Aims: The proinflammatory milieu in cancer patients may expose them to increased risk for acute kidney injury (AKI) after IV contrast (CON). The aims of this study were to determine: (1) the rates of AKI after CON and noncontrast (NC) CT scans in cancer inpatients, (2) if rates differed among cancer subtypes, and (3) whether recent chemotherapy, comorbid conditions, or nephrotoxins increase AKI after CON. Conclusion: In cancer patients, eGFR below 59 mL/min/1.73m2 were associated with increased rate of AKI, independent of contrast exposure. Congestive heart failure and prior AKI were also associated with increased rates of AKI.
    Rate and risk factors for AKI after CT scans in a cancer cohort
    Sheron Latcha et al.
    Clin Nephrol. 2019 Mar;91(3):147-154.

  • Rate and risk factors for AKI after CT scans in a cancer cohort
    Sheron Latcha et al.
    Clinical Nephrology, Vol. 91 – No. 3/2019 (147-154)
  • “This is the largest retrospective study to date that has examined the rate of AKI after NC and CON CT scans in a cancer cohort at a comprehensive cancer center. AKI was significantly associated with lower baseline eGFRs, independent of contrast exposure. Additional risk factors for AKI in cancer patients were the administration of chemo- therapy within ≤ 60 days of CT, CHF, and prior AKI. The observed rate of AKI after IV contrast in a large cancer cohort was not appreciably different from prior reports on non-cancer cohorts.”
    Rate and risk factors for AKI after CT scans in a cancer cohort
    Sheron Latcha et al.
    Clinical Nephrology, Vol. 91 – No. 3/2019 (147-154)
  • OBJECTIVE. The purpose of this article is to evaluate the incidence of contrast-induced nephropathy (CIN) and the effects of associated risk factors in patients with multiple myeloma undergoing contrast-enhanced CT (CECT) with IV administration of nonionic iodinated contrast agent.
    CONCLUSION. The incidence of CIN in patients with multiple myeloma with a normal creatinine level is low and correlates with β2-microglobulin levels. The administration of contrast agent in this patient population is safe but should be based on the potential benefit of the examination and the expected low risk of developing CIN.
    Incidence of Contrast-Induced Nephropathy in Patients With Multiple Myeloma Undergoing Contrast-Enhanced CT
    Jay K. Pahade et al.
    AJR 2011; 196:1094–1101
  • 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)
  • “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
  • Warming of ICM is recommended as follows
    - High rate i.v. LOCM power injectors (>5 mL/sec)
    - Injections of viscous LOCM iodinated contrast media with concentrations above 300 mgI/mL
    - Intravenously injected arterial studies in which timing and peak enhancement are critical
  • OBJECTIVE. The purpose of this study was to quantify temporal variability in vascular and parenchymal enhancement within the same patient and to determine technique-related factors contributing to this variability.
    CONCLUSION. Approximately one-third of patients may show clinically relevant variability in enhancement of the abdominal aorta, portal vein, and liver parenchyma even when using identical scanning and injection parameters. Delay time was the only controllable factor associated with variability in enhancement of the abdominal aorta; no other controllable factor is associated with variability in the portal vein or liver parenchyma.
    Evaluation of Intraindividual Contrast Enhancement Variability for Determining the Maximum Achievable Consistency in CT
    Johnson DY et al.
    AJR 2020; 214:18–23
  • "Our study showed high variability in vascular and parenchymal contrast enhancement at different time intervals even under ideal conditions when patient-related and technique-related factors are held constant. Of all the potential factors that may be responsible for this variability, time delay had the largest impact, suggesting potentially large temporal variability in cardiac output within the same patient.”
    Evaluation of Intraindividual Contrast Enhancement Variability for Determining the Maximum Achievable Consistency in CT
    Johnson DY et al.
    AJR 2020; 214:18–23
  • Purpose: The study sought to compare radiologist’s ability to 1) visualize the appendix; 2) diagnose acute appendicitis; and 3) diagnose alternative pathologies responsible for acute abdominal pain among adult patients undergoing computed tomography (CT) scan with 3 different protocols: 1) intravenous (IV) contrast only; 2) IV and oral contrast with 1-hour transit time; and 3) IV and oral contrast with 3-hour transit time.
    Conclusions: Our findings suggest that reader confidence in visualizing the appendix improved with addition of oral contrast as compared to IV contrast alone. One- and 3-hour oral regimens have a similar diagnostic performance in diagnosing appendicitis.
    Intravenous and Oral Contrast vs Intravenous Contrast Alone Computed Tomography for the Visualization of Appendix and Diagnosis of Appendicitis in Adult Emergency Department Patients
    Wadhwani A et al.
    Canadian Association of Radiologists Journal, 67(3), 234–241.
  • Results: Frequency of visualizing the appendix within IV group alone was 87.3%, IV with oral for 1 hour was 94.1%, and IV with oral for 3 hours was 93.8%. Both oral contrast groups had 100% sensitivity and negative predictive value in diagnosis of acute appendicitis. Specificity for the 1- and 3-hour oral contrast groups was 94.1% and 96.1%, respectively and positive predictive value for both groups was 92%.
    Intravenous and Oral Contrast vs Intravenous Contrast Alone Computed Tomography for the Visualization of Appendix and Diagnosis of Appendicitis in Adult Emergency Department Patients
    Wadhwani A et al.
    Canadian Association of Radiologists Journal, 67(3), 234–241.
  • “Other institutions have suggested that using oral contrast can lead to increased hospital stays. Given the significant economic cost associated with prolonged ED stays, we modified our previous 3-hour protocol to the current 1-hour oral contrast protocol. However, this change did not impact the diagnostic performance as our study shows that sensitivity and NPV in ruling out appendicitis was found to be 100% for IVO1 and IVO3 groups, and the specificity and PPV for both groups was 97.7% and 96.7%, respectively.”
    Intravenous and Oral Contrast vs Intravenous Contrast Alone Computed Tomography for the Visualization of Appendix and Diagnosis of Appendicitis in Adult Emergency Department Patients
    Wadhwani A et al.
    Canadian Association of Radiologists Journal, 67(3), 234–241.
  • “In conclusion, we believe that cross-sectional imaging aids clinicians in determining the underlying cause of acute abdomen and helps guide the appropriate management. While changing our protocol from 3- to 1-hour oral consumption has not impacted the radiological interpretation or the clinical outcomes, a prospective randomized control trial will be required to estimate the effect of IV contrast alone on radiological interpretation and clinical outcomes while evaluating the underlying cause of the patient’s acute abdomen.”
    Intravenous and Oral Contrast vs Intravenous Contrast Alone Computed Tomography for the Visualization of Appendix and Diagnosis of Appendicitis in Adult Emergency Department Patients
    Wadhwani A et al.
    Canadian Association of Radiologists Journal, 67(3), 234–241.
  • Background: Although there is good evidence that warming of contrast media changes the bolus kinetics and injection pressure of iodinated contrast media, there has been little evidence that it affects clinical adverse event rates in a meaningful way.
    Objective: To determine whether the extrinsic warming of low-osmolality iodinated contrast media to 37°C reduced adverse reactions.
    Conclusion: Extrinsic warming to 37°C before intravenous administration was associated with a reduction in the rate of allergic-like reactions to iopromide 370, iopamidol 370, and iohexol 350.
    Extrinsic warming of low-osmolality iodinated contrast media to 37°C reduced the rate of allergic-like reaction
    Bin Zhang et al.
    Allergy Asthma Proc 39:e55–e63, 2018; doi: 10.2500/aap.2018.39.4160)
  • “Iodinated contrast media are considered medications. Therefore, the warming of iodinated contrast media is regulated by the Joint Commission, which mandates if contrast media are to be extrinsically warmed. It is important to provide conclusive evidence that shows that the warming of contrast medium is practical (e.g., a daily temperature log and regular maintenance for each incubator) and cost effective. Therefore, the present study aimed to determine whether the extrinsic warming of LOCM to human body temperature (37C) before routine i.v. administration during computed tomography (CT) reduces adverse reaction rates.”
    Extrinsic warming of low-osmolality iodinated contrast media to 37°C reduced the rate of allergic-like reaction
    Bin Zhang et al.
    Allergy Asthma Proc 39:e55–e63, 2018; doi: 10.2500/aap.2018.39.4160)
  • "Extrinsic warming to 37°C reduced allergic-like reaction rates to iopromide 370, iopamidol 370, and iohexol 350, which are LOCM. The results of the present study were clinically significant and were in accordance to the latest contrast media guidelines. Moreover, contrast media guideline promote a practical way of ad- ministering medications to help alleviate patient burden.”
    Extrinsic warming of low-osmolality iodinated contrast media to 37°C reduced the rate of allergic-like reaction
    Bin Zhang et al.
    Allergy Asthma Proc 39:e55–e63, 2018; doi: 10.2500/aap.2018.39.4160)
  • Why Warm Iodinated Contrast?
    - Warming from room (25°C) to body temperature (37°C) reduces viscosity by 50%
    - Warming reduces injection pressures needed for higher injection rates needed to improve vascular opacification
    - Warming (to 37°C) has NO EFFECT on adverse event rates with LOCM at 300mgI/mL or lower concentrations at injection speeds less than 6 mL/sec
    - Warming of concentrations above 300 mgI/mL ‐ 3X reduction of extravasation and incidence of adverse events
    - Viscosity of Iodixanol at 25C = 26.6cP ~ 15x normal; viscosity of iodixanol at 37C = 11.8cP ~7x normal ‐ so warming to body temperature reduces viscosity by 50%
  • Warming of ICM is recommended as follows
    - High rate i.v. LOCM power injectors (>5 mL/sec)
    - Injections of viscous LOCM iodinated contrast media with concentrations above 300 mgI/mL
    - Intravenously injected arterial studies in which timing and peak enhancement are critical

  • Best Practices in the Use of Iodinated Contrast Media in the Clinical Setting: What the Pharmacist Needs to Know
    American Society of Health-System Pharmacists
  • Delayed Contrast Reactions
    - Definition: An event occurring more than 1 hour to 1 week after ICM injection; majority occur between 3 hrs and 2 days
    - Incidence: 0.5%–14% • More common with iso‐osmolar dimer (IOCM): Iodixanol (Visipaque®): 10 – 14%3,4,5,6 • Even more common in patients treated with Interleukin‐2 (up to 2 yrs)
    - Clinical features
    --- Seldom reported to Radiologist
    - Majority cutaneous adverse events (persistent skin rash with or without itching)
    - Usually mild to moderate severity, rarely requires hospitalization or is life‐threatening
    - May require symptomatic treatment (antihistamines and/or corticosteroids; antipyretics; anti‐emetics; fluids)
  • Delayed Adverse Reactions: Recurrence and Prophylaxis
    - Recurrence rates are 25% or higher
    - T‐Cell mediated hypersensitivity – efficacy of corticosteroid and/or
    - H1‐ antihistamine prophylaxis is unknown1
    - Premedication prophylaxis is not currently recommended with only a history of mild delayed cutaneous reactions ‐ recommend alternative LOCM be used
  • Metformin: What’s the latest news?
    - Metformin does not increase risk of CIN
    - Patients who develop PC‐AKI while taking metformin are susceptible to lactic acidosis
    - Normally, 90% of metformin is excreted unchanged by the kidneys in 24 hrs. Incidence of lactic acidosis (Radiology): 0 to 0.084 cases per 1,000 patient years
    - Patient mortality : Metabolic acidosis ~ 50%
  • Metformin: What’s the latest news?
    Patient Management is risk‐based
    Category I: Patients with no evidence of AKI and eGFR ≥30 mL/min/1.73m2, there is NO need to discontinue metformin either prior to or following ICM administration, nor is there an obligatory requirement to reassess the patient’s renal function following the procedure
    Category II: Patients with acute kidney injury or moderate to severe chronic kidney disease (defined as eGFR < 30), or are undergoing arterial catheter studies that might result in emboli to the renal arteries, metformin should be temporarily discontinued at the time of the procedure, withheld for 48 hours, and reinstituted ONLY after renal function has found to be normal
  • OBJECTIVE. The purpose of this study was to quantify temporal variability in vascular and parenchymal enhancement within the same patient and to determine technique-related factors contributing to this variability.
    CONCLUSION. Approximately one-third of patients may show clinically relevant variability in enhancement of the abdominal aorta, portal vein, and liver parenchyma even when using identical scanning and injection parameters. Delay time was the only controllable factor associated with variability in enhancement of the abdominal aorta; no other controllable factor is associated with variability in the portal vein or liver parenchyma.
    Evaluation of Intraindividual Contrast Enhancement Variability for Determining the Maximum Achievable Consistency in CT
    Johnson DY et al.
    AJR 2020; 214:18–23
  • "Our study showed high variability in vascular and parenchymal contrast enhancement at different time intervals even under ideal conditions when patient-related and technique-related factors are held constant. Of all the potential factors that may be responsible for this variability, time delay had the largest impact, suggesting potentially large temporal variability in cardiac output within the same patient.”
    Evaluation of Intraindividual Contrast Enhancement Variability for Determining the Maximum Achievable Consistency in CT
    Johnson DY et al.
    AJR 2020; 214:18–23
  • Purpose: The study sought to compare radiologist’s ability to 1) visualize the appendix; 2) diagnose acute appendicitis; and 3) diagnose alternative pathologies responsible for acute abdominal pain among adult patients undergoing computed tomography (CT) scan with 3 different protocols: 1) intravenous (IV) contrast only; 2) IV and oral contrast with 1-hour transit time; and 3) IV and oral contrast with 3-hour transit time.
    Conclusions: Our findings suggest that reader confidence in visualizing the appendix improved with addition of oral contrast as compared to IV contrast alone. One- and 3-hour oral regimens have a similar diagnostic performance in diagnosing appendicitis.
    Intravenous and Oral Contrast vs Intravenous Contrast Alone Computed Tomography for the Visualization of Appendix and Diagnosis of Appendicitis in Adult Emergency Department Patients
    Wadhwani A et al.
    Canadian Association of Radiologists Journal, 67(3), 234–241.
  • Results: Frequency of visualizing the appendix within IV group alone was 87.3%, IV with oral for 1 hour was 94.1%, and IV with oral for 3 hours was 93.8%. Both oral contrast groups had 100% sensitivity and negative predictive value in diagnosis of acute appendicitis. Specificity for the 1- and 3-hour oral contrast groups was 94.1% and 96.1%, respectively and positive predictive value for both groups was 92%.
    Intravenous and Oral Contrast vs Intravenous Contrast Alone Computed Tomography for the Visualization of Appendix and Diagnosis of Appendicitis in Adult Emergency Department Patients
    Wadhwani A et al.
    Canadian Association of Radiologists Journal, 67(3), 234–241.
  • “Other institutions have suggested that using oral contrast can lead to increased hospital stays. Given the significant economic cost associated with prolonged ED stays, we modified our previous 3-hour protocol to the current 1-hour oral contrast protocol. However, this change did not impact the diagnostic performance as our study shows that sensitivity and NPV in ruling out appendicitis was found to be 100% for IVO1 and IVO3 groups, and the specificity and PPV for both groups was 97.7% and 96.7%, respectively.”
    Intravenous and Oral Contrast vs Intravenous Contrast Alone Computed Tomography for the Visualization of Appendix and Diagnosis of Appendicitis in Adult Emergency Department Patients
    Wadhwani A et al.
    Canadian Association of Radiologists Journal, 67(3), 234–241.
  • “In conclusion, we believe that cross-sectional imaging aids clinicians in determining the underlying cause of acute abdomen and helps guide the appropriate management. While changing our protocol from 3- to 1-hour oral consumption has not impacted the radiological interpretation or the clinical outcomes, a prospective randomized control trial will be required to estimate the effect of IV contrast alone on radiological interpretation and clinical outcomes while evaluating the underlying cause of the patient’s acute abdomen.”
    Intravenous and Oral Contrast vs Intravenous Contrast Alone Computed Tomography for the Visualization of Appendix and Diagnosis of Appendicitis in Adult Emergency Department Patients
    Wadhwani A et al.
    Canadian Association of Radiologists Journal, 67(3), 234–241.
  • Background: Although there is good evidence that warming of contrast media changes the bolus kinetics and injection pressure of iodinated contrast media, there has been little evidence that it affects clinical adverse event rates in a meaningful way.
    Objective: To determine whether the extrinsic warming of low-osmolality iodinated contrast media to 37°C reduced adverse reactions.
    Conclusion: Extrinsic warming to 37°C before intravenous administration was associated with a reduction in the rate of allergic-like reactions to iopromide 370, iopamidol 370, and iohexol 350.
    Extrinsic warming of low-osmolality iodinated contrast media to 37°C reduced the rate of allergic-like reaction
    Bin Zhang et al.
    Allergy Asthma Proc 39:e55–e63, 2018; doi: 10.2500/aap.2018.39.4160)
  • “Iodinated contrast media are considered medications. Therefore, the warming of iodinated contrast media is regulated by the Joint Commission, which mandates if contrast media are to be extrinsically warmed. It is important to provide conclusive evidence that shows that the warming of contrast medium is practical (e.g., a daily temperature log and regular maintenance for each incubator) and cost effective. Therefore, the present study aimed to determine whether the extrinsic warming of LOCM to human body temperature (37C) before routine i.v. administration during computed tomography (CT) reduces adverse reaction rates.”
    Extrinsic warming of low-osmolality iodinated contrast media to 37°C reduced the rate of allergic-like reaction
    Bin Zhang et al.
    Allergy Asthma Proc 39:e55–e63, 2018; doi: 10.2500/aap.2018.39.4160)
  • "Extrinsic warming to 37°C reduced allergic-like reaction rates to iopromide 370, iopamidol 370, and iohexol 350, which are LOCM. The results of the present study were clinically significant and were in accordance to the latest contrast media guidelines. Moreover, contrast media guideline promote a practical way of ad- ministering medications to help alleviate patient burden.”
    Extrinsic warming of low-osmolality iodinated contrast media to 37°C reduced the rate of allergic-like reaction
    Bin Zhang et al.
    Allergy Asthma Proc 39:e55–e63, 2018; doi: 10.2500/aap.2018.39.4160)
  • Why Warm Iodinated Contrast?
    - Warming from room (25°C) to body temperature (37°C) reduces viscosity by 50%
    - Warming reduces injection pressures needed for higher injection rates needed to improve vascular opacification
    - Warming (to 37°C) has NO EFFECT on adverse event rates with LOCM at 300mgI/mL or lower concentrations at injection speeds less than 6 mL/sec
    - Warming of concentrations above 300 mgI/mL ‐ 3X reduction of extravasation and incidence of adverse events
    - Viscosity of Iodixanol at 25C = 26.6cP ~ 15x normal; viscosity of iodixanol at 37C = 11.8cP ~7x normal ‐ so warming to body temperature reduces viscosity by 50%
  • Warming of ICM is recommended as follows
    - High rate i.v. LOCM power injectors (>5 mL/sec)
    - Injections of viscous LOCM iodinated contrast media with concentrations above 300 mgI/mL
    - Intravenously injected arterial studies in which timing and peak enhancement are critical

  • Best Practices in the Use of Iodinated Contrast Media in the Clinical Setting: What the Pharmacist Needs to Know
    American Society of Health-System Pharmacists
  • Delayed Contrast Reactions
    - Definition: An event occurring more than 1 hour to 1 week after ICM injection; majority occur between 3 hrs and 2 days
    - Incidence: 0.5%–14% • More common with iso‐osmolar dimer (IOCM): Iodixanol (Visipaque®): 10 – 14%3,4,5,6 • Even more common in patients treated with Interleukin‐2 (up to 2 yrs)
    - Clinical features
    --- Seldom reported to Radiologist
    - Majority cutaneous adverse events (persistent skin rash with or without itching)
    - Usually mild to moderate severity, rarely requires hospitalization or is life‐threatening
    - May require symptomatic treatment (antihistamines and/or corticosteroids; antipyretics; anti‐emetics; fluids)
  • Delayed Adverse Reactions: Recurrence and Prophylaxis
    - Recurrence rates are 25% or higher
    - T‐Cell mediated hypersensitivity – efficacy of corticosteroid and/or
    - H1‐ antihistamine prophylaxis is unknown1
    - Premedication prophylaxis is not currently recommended with only a history of mild delayed cutaneous reactions ‐ recommend alternative LOCM be used
  • Metformin: What’s the latest news?
    - Metformin does not increase risk of CIN
    - Patients who develop PC‐AKI while taking metformin are susceptible to lactic acidosis
    - Normally, 90% of metformin is excreted unchanged by the kidneys in 24 hrs. Incidence of lactic acidosis (Radiology): 0 to 0.084 cases per 1,000 patient years
    - Patient mortality : Metabolic acidosis ~ 50%
  • Metformin: What’s the latest news?
    Patient Management is risk‐based
    Category I: Patients with no evidence of AKI and eGFR ≥30 mL/min/1.73m2, there is NO need to discontinue metformin either prior to or following ICM administration, nor is there an obligatory requirement to reassess the patient’s renal function following the procedure
    Category II: Patients with acute kidney injury or moderate to severe chronic kidney disease (defined as eGFR < 30), or are undergoing arterial catheter studies that might result in emboli to the renal arteries, metformin should be temporarily discontinued at the time of the procedure, withheld for 48 hours, and reinstituted ONLY after renal function has found to be normal
  • Purpose To determine if administering IV contrast for CT abdomen and pelvis improves detection of urgent and clinically important non-urgent pathology in patients with urgent clinical symptoms compared to patients not receiving IV contrast, and in turn to determine whether repeat CT exams on the same patient within 72 h were of low diagnostic benefit if the first CT was performed with IV contrast.
    Conclusion In the absence of contraindications, encouraging urgent care physicians to preferentially order IV contrast-enhanced CT AP examinations in adherence with ACR appropriateness criteria may increase detection of urgent pathology and avoid short- term repeat CT.
    Effect of intravenous contrast for CT abdomen and pelvis on detection of urgent and non-urgent pathology: can repeat CT within 72 hours be avoided?
    Lamoureux C et al.
    Emergency Radiology (2019) 26:601–608
  • Methods We evaluated 400 consecutive patients who had CT abdomen and pelvis (CT AP) examinations repeated within 72 h. For each patient, demographic data, reason for examination, examination time stamps, and examination technique were documented. CT AP radiology reports were reviewed and both urgent and non-urgent pathology was extracted.
    Results Of 400 patients, 63% had their initial CT AP without contrast. Administration of IV contrast for the first CT AP was associated with increased detection of urgent findings compared with non-contrast CT (p = 0.004) and a contrast-enhanced CT AP following an initial non-contrast CT AP examination better characterized both urgent (p = 0.002) and non-urgent findings (p < 0.001). Adherence to ACR appropriateness criteria for IV contrast administration was associated with increased detection of urgent pathology on the first CT (p = 0.02), and the second CT was more likely to be performed with IV contrast if recommended by the radiologist reading the first CT (p = 0.0006).
    Effect of intravenous contrast for CT abdomen and pelvis on detection of urgent and non-urgent pathology: can repeat CT within 72 hours be avoided?
    Lamoureux C et al.
    Emergency Radiology (2019) 26:601–608
  • “In our study of patients with duplicate CT abdomen and pelvis within 72 h, the majority of CT exams repeated within the first 6 h were performed first without IV contrast followed by a second CT with IV contrast. Urgent findings were more likely to be detected on the first CT when IV contrast was used. While this may be influenced by patient selection, it could speak to the importance of IV contrast usage in making a rapid definitive ED diagnosis. Furthermore, urgent findings were more likely to be better characterized on the second CT when the first CT was performed without IV contrast followed by IV contrast on the second CT. Our study suggests that in patients with acute abdominal and pelvic symptoms for whom CT abdomen and pelvis is clinically warranted, IV contrast administration should be strongly considered.”
    Effect of intravenous contrast for CT abdomen and pelvis on detection of urgent and non-urgent pathology: can repeat CT within 72 hours be avoided?
    Lamoureux C et al.
    Emergency Radiology (2019) 26:601–608
  • “The results of this study advance our understanding of how administration of intravenous contrast administration for CT of the abdomen and pelvis influence detection of urgent and non-urgent clinically important pathology in the urgent setting. To reduce potentially medically unnecessary redundant imaging within a short timeframe, this information may be useful for optimization of CT examination protocols.”
    Effect of intravenous contrast for CT abdomen and pelvis on detection of urgent and non-urgent pathology: can repeat CT within 72 hours be avoided?
    Lamoureux C et al.
    Emergency Radiology (2019) 26:601–608
  • “Extrinsic warming of room- temperature iodinated contrast material to human body temperature (37°C) is known to reduce contrast material viscosity, and results of some studies have shown that the practice can improve contrast material delivery rates with both hand and power injections through intravenous catheters.”


    Rate of Contrast Material Extravasations and Allergic-like Reactions: Effect of Extrinsic Warming of Low-Osmolality Iodinated CT Contrast Material to 37° C 
Davenport MS et al.
Radiology 2012; 262:475-484
  • “Extrinsic warming of iodinated contrast material to 37°C reduces contrast ma- terial viscosity and has been advocated to decrease the frequency of adverse events related to intravenous administration and to improve iodinated contrast material delivery.”


    Rate of Contrast Material Extravasations and Allergic-like Reactions: Effect of Extrinsic Warming of Low-Osmolality Iodinated CT Contrast Material to 37° C 
Davenport MS et al.
Radiology 2012; 262:475-484
  • STUDY OBJECTIVE: The study objective was to determine whether intravenous contrast administration for computed tomography (CT) is independently associated with increased risk for acute kidney injury and adverse clinical outcomes.

    CONCLUSION: In the largest well-controlled study of acute kidney injury following contrast administration in the ED to date, intravenous contrast was not associated with an increased frequency of acute kidney injury.
Risk of Acute Kidney Injury After Intravenous Contrast Media Administration.


    Hinson JS, Ehmann MR, Fine DM, Fishman EK, Toerper MF, Rothman RE,  Klein EY 
Ann Emerg Med 2017 Jan 19. pii: S0196-0644(16)31388-9 

  • “Rates of acute kidney injury were similar among all groups. Contrast administration was not associated with increased incidence of acute kidney injury (contrast-induced nephropathy criteria odds ratio=0.96, 95% confidence interval 0.85 to 1.08; and Acute Kidney Injury Network/Kidney Disease Improving Global Outcomes criteria odds ratio=1.00, 95% confidence interval 0.87 to 1.16). This was true in all subgroup analyses regardless of baseline renal function and whether comparisons were made directly or after propensity matching. Contrast administration was not associated with increased incidence of chronic kidney disease, dialysis, or renal transplant at 6 months.”
Risk of Acute Kidney Injury After Intravenous Contrast Media Administration.


    Hinson JS, Ehmann MR, Fine DM, Fishman EK, Toerper MF, Rothman RE,  Klein EY 
Ann Emerg Med 2017 Jan 19. pii: S0196-0644(16)31388-9 

  • OBJECTIVE. The objective of our study was to determine the effects of dehydration and oral rehydration on the incidence of acute adverse reactions to iodinated contrast media administered during abdominal and pelvic CT in outpatients.


    CONCLUSION. Dehydration and oral rehydration did not affect the incidence of acute adverse reactions to iodinated contrast material for abdominal and pelvic CT in our randomized prospective trial.

    
Acute Adverse Reactions to Nonionic Iodinated Contrast Media for CT: Prospective Randomized Evaluation of the Effects of Dehydration, Oral Rehydration, and Patient Risk Factors
Utaroh Motosugi et al.
AJR 2016;207: 931-938.
  • “In general, fluid intake is recommended to prevent CIN . However, on the basis of our results, there is no reason to promote fluid intake to prevent acute adverse reactions. Fluid intake does not help patients feel comfortable with the IV contrast injection. On the other hand, fluid intake immediately before CT did not increase the prevalence of adverse reactions. Thus, there is also no reason, to our knowledge, to advise patients to avoid fluid consumption before contrast- enhanced CT.”


    Acute Adverse Reactions to Nonionic Iodinated Contrast Media for CT: Prospective Randomized Evaluation of the Effects of Dehydration, Oral Rehydration, and Patient Risk Factors
Utaroh Motosugi et al.
AJR 2016;207: 931-938.
  • “In conclusion, in our randomized prospective study, neither dehydration nor oral rehydration affected the prevalence of acute adverse reactions to iodinated contrast media administered during abdominal and pelvic CT.”


    Acute Adverse Reactions to Nonionic Iodinated Contrast Media for CT: Prospective Randomized Evaluation of the Effects of Dehydration, Oral Rehydration, and Patient Risk Factors
Utaroh Motosugi et al.
AJR 2016;207: 931-938.
  • “AAA represents a progressive increase in the aortic luminal diameter and is the 10th most common cause of death in the Western world. AAA is usually described by its relationship to renal arteries (ie, suprarenal or infrarenal). The normal diameter of the suprarenal abdominal aorta is up to 3.0 cm, and that of the infrarenal abdominal aorta is 2.0 cm. Aneurysmal dilation of the infrarenal aorta is defined as a diameter ≥3.0 cm or dilation of the aorta ≥1.5 times the normal diameter; on the basis of these criteria, 9% of people aged >65 years have an AAA.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Emergency surgery for aortic aneurysm rupture is associated with 46% mortality (as opposed to 4%-6% for elective repair), and rupture occurs with increasing frequency as the aneurysm size exceeds 5 cm. It is therefore valuable to detect AAAs and follow up until elective repair is indicated.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • When do you followup aneurysms for interval change?
    Aortic Diameter (cm) Imaging Interval
    2.5-2.9                                   5 y
    3.0-3.4                                   3 y
    3.5-3.9                                   2 y
    4.0-4.4                                   1 y
    4.5-4.9                                   6 mo
    5.0-5.5                                   3-6 mo
  • “Aneurysms involve common and internal iliac arteries more commonly than external iliac arteries. Iliac artery aneurysm is defined as a vessel diameter ≥1.5 times the normal iliac artery diameter or ≥2.5 cm in diameter. Iliac artery aneurysms are rare in isolation; Lawrence et al reported a prevalence of 6.58 per 100,000 hospitalized men and 0.26 per 100,000 hospitalized women in the United States. Aneurysms that are <3.0 cm in diameter tend to be asymptomatic, rarely rupture, and expand slowly; those that are 3.0 to 3.5 cm should be followed up with cross-sectional imaging initially at about 6 months. If stable, repeat scanning can be performed annually. Iliac artery aneurysms >3.5 cm have a greater tendency to rupture and should be followed more closely or treated expeditiously.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Aneurysms involve common and internal iliac arteries more commonly than external iliac arteries. Iliac artery aneurysm is defined as a vessel diameter ≥1.5 times the normal iliac artery diameter or ≥2.5 cm in diameter. Iliac artery aneurysms are rare in isolation; Lawrence et al reported a prevalence of 6.58 per 100,000 hospitalized men and 0.26 per 100,000 hospitalized women in the United States. Aneurysms that are <3.0 cm in diameter tend to be asymptomatic, rarely rupture, and expand slowly; those that are 3.0 to 3.5 cm should be followed up with cross-sectional imaging initially at about 6 months. If stable, repeat scanning can be performed annually.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Splenic artery aneurysms are the most common visceral aneurysms and the third most common intra-abdominal aneurysm, after those occurring in the aorta and iliac arteries . In a series of >300 visceral artery aneurysms, 70.9% were of the splenic artery. The vast majority are true aneurysms, although pseudoaneurysms related to prior inflammation, especially pancreatitis, or infection may occur. The estimates of prevalence of splenic artery aneurysms vary, but a retrospective review of nonselective angiograms suggests that an incidence estimate of 0.8% may be the most accurate .”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Risk factors for developing these aneurysms are similar to those for other aneurysms. In a review of the clinical features of 217 patients with splenic artery aneurysms, hypertension was present in 50.2%, obesity in 27.6%, coronary artery disease in 23.5%, and hypercholesterolemia in 21.7%. Splenic artery aneurysms occur more frequently in women .”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Spontaneous rupture of a splenic artery aneurysm is rare, especially for smaller (<2 cm) aneurysms, but may occur, usually with larger aneurysms. Additional risk factors associated with rupture include rapidly increasing size, occurrence in women of childbearing years, cirrhosis (especially associated with α1 antitrypsin deficiency), and symptoms that can be attributable to the aneurysm.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “The surgical literature suggests a consensus that such an aneurysm should be considered for endovascular therapy when ≥2 cm. Smaller aneurysms probably can be safely followed, although the clinical risk factors for rupture should be carefully assessed. In one review of patients who were followed with small splenic artery aneurysms, the mean aneurysm growth rate was 0.06 cm/y, with the most rapid growth rate noted to be 1 cm over 63 months. In this group of patients, none of the aneurysms ruptured. Given these data, yearly surveillance for small splenic artery aneurysms is recommended, although for the smaller aneurysms among those ≥2 cm, surveillance intervals of >1 year may be reasonable, depending on comorbidities and life expectancy.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “RAA is uncommon, occurring in about 0.09% of the population . Etiologies include fibromuscular dysplasia (FMD), atherosclerosis, and pseudoaneurysms that may occur after trauma. In a review of 168 patients with 252 RAAs, 34% had FMD, 25% had atherosclerosis, 6.5% had concurrent aneurysms of other vessels, and 73% had hypertension [22]. RAAs are usually detected incidentally at cross-sectional imaging, are small, are asymptomatic, and have uncertain clinical relevance. However, they may rupture, especially if they enlarge, and may be associated with renal arterial hypertension.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “One approach that has been suggested is to repair all aneurysms ≥1 cm in patients with uncontrolled hypertension. An incidentally discovered RAA measuring 1.0 to 1.5 cm can be safely followed . In a series of 86 RAAs with a mean size of 1.3 cm, none ruptured after an average follow-up of 72 months. We recommend that a reasonable imaging follow-up interval in these asymptomatic individuals is every 1 to 2 years. Larger aneurysms, measuring >1.5 to 2.0 cm, should be considered for surgical or endovascular repair .”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “One approach that has been suggested is to repair all aneurysms ≥1 cm in patients with uncontrolled hypertension. An incidentally discovered RAA measuring 1.0 to 1.5 cm can be safely followed . In a series of 86 RAAs with a mean size of 1.3 cm, none ruptured after an average follow-up of 72 months. We recommend that a reasonable imaging follow-up interval in these asymptomatic individuals is every 1 to 2 years. Larger aneurysms, measuring >1.5 to 2.0 cm, should be considered for surgical or endovascular repair .”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Outside of the splenic and renal circulations, visceral aneurysms can affect the celiac, hepatic, gastroduodenal, pancreaticoduodenal, gastric, or mesenteric arteries. After splenic and renal arterial aneurysms, the hepatic artery is the next most common location. When discovered incidentally, these aneurysms are typically caused by atherosclerosis and may be associated with aneurysmal disease elsewhere. They can also be mycotic, traumatic (including iatrogenic trauma for hepatic aneurysms after liver biopsy), or, less commonly, related to polyarteritis nodosa, FMD, or visceral inflammatory disease, such as pancreatitis.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Treatment is generally recommended for aneurysms >2 cm in diameter, possibly with a smaller threshold for nonatherosclerotic aneurysm. For hepatic aneurysms, Abbas et al  established that multiplicity and nonatherosclerotic origin were linked to increased rupture rate. Criteria for which it is safe to observe visceral arterial aneurysms have not been clearly established. In the study of Abbas et al, of 21 patients with a mean follow-up interval of 68.4 months and mean diameter of 2.3 cm, none required intervention during the follow-up period.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Ovarian veins originate from the plexus in the broad ligament near the ovary and fallopian tubes and communicate with the uterine plexus, then course anterior to the psoas muscle and the ureter. The right ovarian vein typically drains into the IVC and the left ovarian vein into the left renal vein. Autopsy studies have shown that valves are absent in the cranial portion of the ovarian vein in 15% of women on the left and 6% on the right . The valves are incompetent on either side in 35% to 43%, with a higher frequency in multiparous women, resulting in dilation >8 mm and incompetence in many asymptomatic patients who undergo CT.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Incompetence of the ovarian and draining pelvic veins and venous reflux are considered the main cause of pelvic congestion syndrome in women, symptoms of which include persistent dull pelvic pain lasting >6 months, dysmenorrhea, dyspareunia, postcoital ache, and urinary symptoms. However, dilated pelvic veins are often seen incidentally in asymptomatic multiparous women . If dilated pelvic veins are noted in a woman and are asymptomatic, no further imaging or intervention is recommended..”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “In a CT angiographic study of potential renal donors, dilated ovarian veins were found in 16 (47%) of 34 asymptomatic women . In another CT study of patients with severe ovarian vein reflux, but without PCS, both right and left parauterine veins were tortuous and dilated in all cases, with a mean vein diameter of 5.9 ± 1.6 mm (range, 4.3-8.0 mm). Pelvic varices, and early opacification and dilation of the gonadal veins, may occur without venous reflux, particularly if uterine fibroids or other pelvic abnormalities are present.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Gonadal vein thrombosis can be seen in up to 80% of asymptomatic women who undergo routine CT after hysterectomy and lymphadenectomy for neoplasm. When acute, the central thrombus typically demonstrates low attenuation and is associated with mural enhancement. The vessel chronically becomes fibrotic and contracted, and phleboliths may develop.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Pancreaticoduodenal aneurysms are felt to be at higher risk for rupture, and all of these aneurysms should be considered for surgical or endovascular treatment.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • Who should get baseline serum creatinine levels before CT?
  • - Age > 60
    - History of renal disease, including:
        - Dialysis
        - Kidney transplant
        - Single kidney
        - Renal cancer
        - Renal surgery
    - History of hypertension requiring medical therapy
    - History of diabetes mellitus
    - Metformin or metformin-containing drug combinations
  • “The major preventive action against CIN is to ensure adequate hydration. The ideal infusion rate and volume is unknown, but isotonic fluids are preferred (Lactated Ringer’s or 0.9% normal saline). One possible protocol would be 0.9% saline at 100 mL/hr, beginning 6 to 12 hours before and continuing 4 to 12 hours after intravascular iodinated contrast medium administration. Oral hydration has also been utilized, but with less demonstrated effectiveness.”
    ACR Manual on Contrast Media
    Version 9 (2013)
  • Contrast Selection for CCTA of Coronary Artery Stents
     - is higher concentration of contrast better for stent opacification
    - what is optimal for stent evaluation?
    - is there a difference between iodixanol-320 and iomeprol-400?
  • Objective: We compared iomeprol-400 with iodixanol-320 to evaluate coronary stents with MDCT-CA
    Conclusions: Iodixanol-320 provides better image quality of coronary stents, allowing higher MDCT-CA evaluability, than iomeprol-400
    Coronary stent evaluation with coronary computed tomographic angiography: Comparison between low-osmolar, high iodine concentration iomeprol-400 and iso-osmolar, lower iodine concentration iodixanol-320
    Andreini D et al.
    J Cardiovasc Comput Tomogr 8(2014) 44-51
  • “ Diminished eGFR is associated with an increased risk of SCr-defined AKI following CT examinations. However, the risk of AKI is independent of contrast material exposure, even in patients with eGFR of less than 30 ml/min/1.73m2.”
    Risk of Intravenous Contrast-mediated Acute Kidney Injury: A Propensity Score-matched Study Stratified by Baseline-estimated Glomerular Filtration Rate
    McDonald JS et al.
    Radiology 2014;271:65-73
  • “ Contrast material induced nephropathy cannot be differentiated from contrast material dependent causes of AKI, in a predominately inpatient cohort, even in patients with severely compromised renal function.”
    Risk of Intravenous Contrast-mediated Acute Kidney Injury: A Propensity Score-matched Study Stratified by Baseline-estimated Glomerular Filtration Rate
    McDonald JS et al.
    Radiology 2014;271:65-73
  • “ In conclusion, our findings provide additional evidence that the administration of intravenous contrast material does not increase the risk of AKI, even in patients with substantially compromised renal function.”
    Risk of Intravenous Contrast-mediated Acute Kidney Injury: A Propensity Score-matched Study Stratified by Baseline-estimated Glomerular Filtration Rate
    McDonald JS et al.
    Radiology 2014;271:65-73
  • BACKGROUND: Previous clinical studies have shown that iso-osmolar iodixanol (Visipaque®) causes less patient discomfort than low-osmolar contrast media (LOCM) when administered via intra-arterial injection. No data are available comparing these agents for patient discomfort when administered intravenously (i.v.) using power injectors.
    PURPOSE:To compare the frequency and intensity of patient discomfort between iodixanol and iopamidol (Isovue®) administered i.v. using a power injector in contrast-enhanced computed tomography (CECT) of the abdomen and pelvis.
    MATERIAL AND METHODS:This was a prospective, randomized, double-blind, multicenter study of iodixanol 320-mg I/mL or iopamidol 370-mg I/mL on patient discomfort. The presence of discomfort (heat, pain, coldness) and intensity was verbally rated by patients on a 0-10 scale and converted into four categories (0, none; 1-3, mild; 4-7, moderate; 8-10, severe). Image quality was evaluated.
    Comparison of patient comfort between iodixanol and iopamidol in contrast-enhanced computed tomography of the abdomen and pelvis: a randomized trial.
    Weiland FL1, Marti-Bonmati L, Lim L, Becker HC.
    Acta Radiol. 2013 Sep 23. [Epub ahead of print]
  • BACKGROUND:Previous clinical studies have shown that iso-osmolar iodixanol (Visipaque®) causes less patient discomfort than low-osmolar contrast media (LOCM) when administered via intra-arterial injection. No data are available comparing these agents for patient discomfort when administered intravenously (i.v.) using power injectors.
    PURPOSE:To compare the frequency and intensity of patient discomfort between iodixanol and iopamidol (Isovue®) administered i.v. using a power injector in contrast-enhanced computed tomography (CECT) of the abdomen and pelvis.
    Comparison of patient comfort between iodixanol and iopamidol in contrast-enhanced computed tomography of the abdomen and pelvis: a randomized trial.
    Weiland FL1, Marti-Bonmati L, Lim L, Becker HC.
    Acta Radiol. 2013 Sep 23. [Epub ahead of print]
  • RESULTS:
    Of the 299 evaluable patients enrolled at nine centers, 151 received iodixanol and 148 received iopamidol. The average age was 58 years. Iodixanol patients experienced significantly less moderate/severe discomfort (35.1% vs. 67.3%; P-<-0.0001) or heat (29.8% vs. 63.9%; P-<-0.0001), and severe discomfort (2.6% vs. 16.3%; P-=-0.0004) or heat (2.6% vs. 15%; P-=-0.0008), but three times more no discomfort (21.2% vs. 7.5%; P-=-0.0008) than iopamidol patients. Excellent image quality was in 95.4% of iodixanol vs. 89.9% of iopamidol patients (P-=-0.0508). Overall, adverse event (AE) rate excluding patient discomfort was 19.9% in the iodixanol group and 14.9% in the iopamidol group (P-=-0.2870), but contrast-related AEs were comparable: 11.3% vs. 10.1% (P-=-0.8522). Delayed skin reactions occurred in 2.6% of patients in the iodixanol group and in no patient in the iopamidol group (P-=-0.1226).
    Comparison of patient comfort between iodixanol and iopamidol in contrast-enhanced computed tomography of the abdomen and pelvis: a randomized trial.
    Weiland FL1, Marti-Bonmati L, Lim L, Becker HC.
    Acta Radiol. 2013 Sep 23. [Epub ahead of print]
  • CONCLUSION:
    Patients receiving iodixanol had significantly lower moderate-to-severe or severe discomfort than patients receiving iopamidol, with heat being the major contributor. Iodixanol use trended towards better image quality but the difference was not statistically significant. No significant differences in incidences of overall or contrast-related AEs or delayed skin reactions were seen between the two groups. These data support that CM osmolality may be a key determinant of patient discomfort.
    Comparison of patient comfort between iodixanol and iopamidol in contrast-enhanced computed tomography of the abdomen and pelvis: a randomized trial.
    Weiland FL1, Marti-Bonmati L, Lim L, Becker HC.
    Acta Radiol. 2013 Sep 23. [Epub ahead of print]
  • “ The safety of iodixanol in routine clinical practice was shown to be similar to the published safety profiles of other non-ionic iodinated contrast agents. Patient discomfort during administration was mild or absent in most patients. Advances in knowledge: The major strength of this study is that it included 20-185 patients enrolled in various types of imaging examinations. The safety profile of iodixanol was comparable to previously published work.”
    Post-marketing surveillance study with iodixanol in 20,185 Chinese patients from routine clinical practices.
    Zhang BC1, Hou L, Lv B Xu YW.
    Br J Radiol. 2014 Feb;87(1034)
  • “ High rate intravenous administration of 80 ml of iopamidol and iodixanol during pulmonary CT angiography slightly increased HR; there was no difference in HR between the contrast agent groups.”
    Comparison of the Effect of Low- and Iso-Osmolar Contrast Agents on Heart Rate during Chest CT Angiography: Results of a Prospective Randomized Multicenter Study
    Chartrand-Lefebvre C et al
    Radiology 2011;258:930-937
  •  “The CT Contrast Protocols application for the iPad and iPhone is one of the first radiology applications in the Apple App Store to focus on radiology education and was designed to address the lack of practical information on contrast media for radiologists, technologists, nurses, and trainees.”
     CT Contrast Protocols Application for the iPad: New Resource for Technologists, Nurses, and Radiologists
    Raman SP, Raminpour S, Horton KM, Fishman EK
    RadioGraphics 2013; 33:913-921
  •  “The developers of the application thought that providing the user with specific questions and answers could be more practically useful on a day-to-day basis than a larger amount of text or information.”
     CT Contrast Protocols Application for the iPad: New Resource for Technologists, Nurses, and Radiologists
    Raman SP, Raminpour S, Horton KM, Fishman EK
    RadioGraphics 2013; 33:913-921
  •  “ We believe that this application, in addition to its educational value, is a clear illustration of the unlimited possibilities that exist in the mobile sphere, particularly on the iPad and iPhone, for radiology educational resource .”
     CT Contrast Protocols Application for the iPad: New Resource for Technologists, Nurses, and Radiologists
    Raman SP, Raminpour S, Horton KM, Fishman EK
    RadioGraphics 2013; 33:913-921
  • “ The three monomeric agents studied (iopamidol 300, iopromide 300, ioxehol 300) and the one dimeric agent (iodixanol 320) were equivalent in terms of lack of a significant effect on measured GFR when administered to patients with normal GFR.”
    Glomerular Filtration Rate in Evaluation of the Effect of Iodinated Contrast Media on Renal Function
    Becker J et al.
    AJR 2013; 200:822-826
  • “ Given the remaining uncertainties about the real incidence of contrast medium-induced nephropathy, how should we practice? It is our recommendation that we be more liberal in our policies in regard to contrast medium administration.”
    Quantitating Contrast Medium-induced Nephropathy: Controlling the Controls
    Newhouse JH, RoyChoudhury
    Radiology 2013; 267:4-8
  • Is it better to use a higher concentration contrast agent for cardiac CT?
  • “We administered 80-100 mL of contrast material [Group 1: Iomeprol, Iomeron 400 mgI/mL, Bracco (Iodine burden = 32-40 grI); Group 2: Iodixanol, Visipaque 320 mgI/mL, GE Healthcare (Iodine burden = 25.6-32 grI)] at an injection rate of 5-6 mL/s [depending on the quality of the venous access; Iodine Delivery Rate (IDR): Group 1 = 2.0-2.4 mgI/s and Group 2 = 1.6-1.92 mgI/s] with an automatic injector (Stellant, MedRad, Pittsburgh, PA, USA) attached to an 18- to 20-gauge needle cannula inserted in an antecubital vein.”
    Plaque imaging with CT angiography: Effect of intravascular attenuation on plaque type classification
    Maffei E et al.
    World J Radiol 2012 Jun 28;4(6):265-272
  • “High intra-vascular attenuation modified significantly the attenuation of non-calcified coronary plaques. As a result, the detection of fibrous vs lipid rich plaques was significantly affected. Image quality was not significantly affected by different settings (i.e., CT scanner and contrast medium used). S/N was significantly better in the Group using lower iodine concentration and with lower intra-vascular attenuation.”
    Plaque imaging with CT angiography: Effect of intravascular attenuation on plaque type classification
    Maffei E et al.
    World J Radiol 2012 Jun 28;4(6):265-272
  • “ Higher intra-vascular attenuation modifies significantly the attenuation of non-calcified coronary plaques. This results in a more difficult characterization between lipid rich vs fibrous type.”
    Plaque imaging with CT angiography: Effect of intravascular attenuation on plaque type classification
    Maffei E et al.
    World J Radiol 2012 Jun 28;4(6):265-272
  • OBJECTIVES:
    To compare vascular and parenchymal contrast enhancement in multidetector computed tomography of the liver using two contrast media with different iodine concentration (Iodixanol 320mgI/mL and Iomeprol 400mgI/mL) and similar viscosity, using fixed total iodine volume (40gI) and iodine delivery rate (1.6gI/s).
    CONCLUSIONS:
    Iodixanol 320 and Iomeprol 400 injected at the same iodine delivery rate (1.6gI/s) and total iodine load (40gI) did not provide statistically significant differences in liver parenchymal and vascular contrast enhancement.
    High concentration (400mgl/mL) versus low concentration (320 mgl/mL) iodinated contrast media in multi detector computed tomography of the liver: A randomized single center, non inferiority study
    Rengo M et al.
    Eur J Radiol 2012 June 8 (Epub ahead of print)
  • Omnipaque-350 vs. Visipaque-320

    - Both work very well for all CT Angiographic studies
    - Despite differences in iodine concentration the opacification of vessels which determine in great part the success of CT angiography are equivalent (Pannu HP, Fishman EK WIP)
  • "Most respondents (75%) perform CT angiography in pregnant patients suspected of having pulmonary embolism, but their policies and practices vary considerably."

    Pulmomary Embolism in Pregnant Patients: A Survey of Practices and Policies for CT Pulmonary Angiography
    Schuster ME et al.
    AJR 2003; 181:1495-1498
  • When is Visapaque always used?

    - Borderline renal function
    - Older patients especially if diabetic
    - Patients who already received one contrast injection in the preceding 24-36 hours
    - All patients premedicated due to prior contrast reaction
    - All pulmonary embolism studies
    - All coronary angiography studies
  • What about saline bolus chasing?

    - Improved use of contrast volume (contrast in IV line and periperal veins (10-15 cc)
    - Ideal in coronary angiography studies to wash dense contrast from the right side of the heart
    - Ideal in patients with borderline renal function to make better use of contrast
    - Decreased volume of contrast needed
  • "Using a saline flush after the contrast material bolus in abdominal CT allows an iodine dose reduction of approximately 6 g, or 17%, without impairing mean parenchymal and vascular enhancement and a cost reduction of $7.30 per patient."

    Abdominal Multidetector Row Computed Tomography: Reduction of Cost and Contrast Material Dose Using Saline Flush
    Schoellnast H et al. J Comput Assist Tomogr 2003;27:847-853
  • "Using 100 ml of contrast material and a saline chaser did not result in a meaningful difference in liver parenchyma attenuation or lesion conspicuity compared with using 150 ml of contrast medium alone.Routine use of a chaser for abdominal CT may yield cost savings and a decreased risk of contrast nephropathy."

    Using a Saline Chaser to Decrease Contrast Media in Abdominal CT
    Dorio PJ et al.
    AJR 2003; 180:929-934

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