Contrast Corner

Treatment of nonionic radiographic contrast material extravasation

Posted on

7/2020

Initial treatment provided by the radiology technologist includes:

  • Immediately discontinue the contrast injection when a problem is detected.
  • Elevation of affected extremity above the heart
  • Removal of any tight fitting clothing above the injection site
  • Milk the extravasated contrast toward the heart by intermittent compression of affected site by manual compression or an Ace wrap
  • Use caution with application of tight bandages (eg, coban) proximal to the extravasation site

Observation performed by nursing staff includes:

  • Typical observation periods depend on patient’s symptoms and site of extravasate.  Often, 1-2 hours are sufficient
  • Educate patient about signs of tissue compromise, and advise to seek medical attention if needed per UW Health Facts for You (HFFY)
  • Hot/cold compresses not specifically indicated, but can be used for comfort.
  • Plastic surgery consultation based on symptoms, not quantity of extravasation

Plastic surgery consultation should be considered for any of the following reasons:

  • Skin blistering
  • Redness or streaks at the injection site
  • Altered tissue perfusion (decreased capillary refill in the region or distal to the injection site)
  • Increasing pain
  • Change in sensation distal to site of extravasation
  • Main clinical concern is development of compartment syndrome.

Patient given Health Facts for You (HFFY) by rad tech if responsive, or printed by nursing prior to discharge.

Bicarb Protocol

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Interventional Radiology Bicarb Protocol for CIN

Indication

Contrast induced or associated AKI is felt to be a real albeit rare entity.  The most important risk factor seems to be pre-existing severe renal insufficiency (AKI or eGFR<30mL/min/1.73m2.  The major preventative action to mitigate the risk of CIN is to provide intravenous volume expansion (see Hydration protocol).  One possible protocol would be 0.9% saline at 100 ml/hr, beginning 6-12 hrs before contrast and continuing for 4-12 hours after contrast in the inpatient setting.

A study from JAMA printed in May of 2004 indicates that hydration with a bicarbonate solution may better prevent contrast induced nephropathy than NS hydration. Most renal failure is associated with metabolic acidosis and low urinary pH. NS may contribute to acidosis while the bicarbonate solution will buffer the pH.3.  Subsequent studies have challenged this practice, and results are not definitive at this time.  However, given the low cost and lack of side effects, it is unlikely to be harmful and could be added to the hydration regimen.  Other practices, such as administration of N-acetyl cysteine, are not supported by the literature.  Cessation of nephrotoxic medications may also be helpful when feasible.

Administration/Dosing

Solution: 150 mEq NaHCO3 in 1000cc D5W

1 hour prior to contrast: Initial IV bolus – 3ml/kg/hour x 1 hour

After 1 hour bolus: 1ml/kg/hour during contrast exposure and 6 hours post contrast.

References

  1. Levy EM, Viscoli CM, Hurwitz RI. The effect of acute renal failure on mortality: a cohort analysis. JAMA. 1996; 275: 1489-1494.
  2. McCullough PA, Wolyn R, Rocher LL, et al. Acute renal failure after coronary intervention. Am J Med.1997; 103: 368-375.
  3. Merten GJ, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA. 2004; 291: 2328-2334.
  4. 2004/Lisa Semmann, R.N., M.S., Interventional Radiology NP

Scheduler CT/MR Screening Guidelines for Patients with Allergy

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Purpose: reduce the number of patients with known allergies scanned at East Clinic, Digestive Health Center, and other non-hospital outpatient centers.

  1. If a patient is being scheduled for a contrast-enhanced CT and has an allergy to iodinated contrast or “contrast” then the study should be done at CSC, TAC or One South Park.
  2. If a patient is being scheduled for a contrast-enhanced MRI and has an allergy to gadolinium-based contrast or “contrast” then the study should be done at CSC, TAC or One South Park.
  3. If the patient has a list of 5 or more allergies to anything and has an order for a contrast-enhanced CT or contrast-enhanced MRI, then the patient should be scheduled at CSC, TAC or One South Park.
  4. If the caller tells the screener that they have had an “anaphylactic” or “anaphylactoid” reaction, and the patient has an order for a contrast-enhanced CT or contrast-enhanced MRI they should be scheduled at CSC or TAC. Please note that the schedulers are not obligated to search the medical records for the severity of reactions.
  5. Pre-medication is only indicated for those patients with known allergies to iodinated contrast or gadolinium-based contrast agents, and should be communicated at the physician level. (See Prophylaxis policy for patients allergic to IV contrast).