Contrast Media and Adverse Effects - Vijay Kumar

7/31/2019 Contrast Media and Adverse Effects - Vijay Kumar

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CONTRAST MEDIA AND ADVERSE

EFFECTS

Varinder singh


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INTRODUCTION

Contrast media are those substances which are usedto distinguish between organ and tissues, vessels by

introducing different methods. Contrast media differs asthe attenuation and absorption of radiation. Contrastmedia having high atomic number and attenuation and

absorption is more so it appears white in the radiograph. Air containing contrast media have low atomic number less attenuation and low absorption of radiation so it

appears black on the radiograph


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HISTORICAL DEVELOPMENT

In 1923 first report of opacification of the urinary tract byrenal excretion by retrograde introduction of contrast agentwith the use of 10% sodium iodide. This was followed by

iodine derivatives of pyridone e.g. of the first contrast mediawas uroselectian and diodone (diotrast) which were utilizedin urography from the 1930. In 1950 that the modern water

Soluble contrast media were introduced into clinicalradiology. There are all derivatives of triodo benzoic acid,the first being acetrizoate (urokon)


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In 1955 a much safer derivative was reported Diatrizoate. This had

on acetamido group. Isomerization of diatrizoate and iothalamatemolecule in 1962. The majority of the modern conventional water soluble contrast media was developed. It contains sodium andmeglumine. These contrast are Hypertonic with osmolalitis. Hyper

osmolality is responsible for many of the adverse effect so lowosmolar contrast media was developed which reduce the sideeffects. Conventional ionic contrast media have a iodine to particleratio was 3:2. In 1972 a new agent was introduced for radiculography. It was iothalamate molecules to form a dimer-iocarmate (Dimer x It was highly toxic so it was discarded CardedThen Hexabrix (mixed sodium and meglumine salt was developed This was developed metrizamide (Amipaque), Iopamidol (Niopamiohexol Omnipaque)

HISTORICAL DEVELOPMENT Contd


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Definition C/MThe contrast media are the salt of organic iodine containing

molecules. They are introduced into the body for the purposeof opacifying structure.

Properties of C/MIt must be easily availableIt must be non toxic / non poisonousViscosity must be adequate

It should not affect locallyIt must provide adequate contrast for diagnostic purposeIt must provide permanent opacification in the radiographIntrathecal contrast should be missible in CSF

Contrast media should be isotonic to blood.


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Types of C/M barium Compounds

Barium suspension is made up from pure barium sulphateIt is morphological studies of GI tractBarium contrast is used in the form of Ba so4

BASO 4: White crystalline power Molecular weight = 233Specific gravity = 4.5

Atomic number = 56High density barium usually has particle size 5 to 12 micrometer Decreasing the particle size increase viscosity.


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Varieties of Barium suppression is used

Proprietary name Density W / V

Baritop 100 100%

E-Z HD 250%

Micro opaque DC 100%

Micro opaque Powder 76%

Polibar Rapid 100%


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Indications

Suspected perforation

To distinguish bowel from other structures on CTLOCM is used if aspiration possiblyIn the case of GI tract of neonates and infants

When C/M is likely to enter the lungPossible leakage of contrast media from the GI tact


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Advantage

Rapid absorption of LOCMNo damage to bowel mucosaVery slow absorption from gutResulting in good bowel visualization

Stable in bowel secretionNo adverse effects on the lungs


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Complications

Pulmonary oedema Allergic reactionMay precipitate in hyper chlorohydric gastric acid


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Iodine containing water soluble contrast media Ionic

Non ionicIonic water saluble c/m (ionic ) (HOCM)a. Urography 60% (Trazograf )

79% Na/ diagrizoate

52% meglumine diatrizoateIodine content 292 mg/ml 5.14gm (In 20ml Solution)

B. Urografin 76% (Trazograf) 7.4gm (In 20ml Solution)10% sodium diatrozoateIodine content 370mg/ml

C. Trazogastro (Gastrografin ) ORAL contrast10% Sodium diatrizoetec66% meglime diatrizoateIodine content 370mg/ml


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Table 1Type of Contrast Agents

Table 2Conditions associated with adverse reactions to contrast Material

Type AgentHigh

OsmolalityIonic Diatrizoate sodium

(Hypaque)LowOsmolality

Ionic Loxaglatemeglumine

(Hexabrix)Nonionic Gadodiamide

(Omniscan)

Gadoteoridol(Pro Hance)Iodixanol (Visipaque)Iopamidol (Isovue)Iopromide (Ultravist)

Ioversol (Optiary)

Preexisting renal insufficiencyPrevious anaphylactoid reaction to contrast material

AsthmaFood or medication allergies, or hayfever Multiple medical problem or an underlying disease ( e.g. cardiacdisease, preexisting azotemia)Treatment with nephrotoxic agents (e.g. aminoglycosides,nonsteroidal anti-inflammatory agents)Advanced age


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Table 3 Methods of Preventing ContrastMaterial induced renal Insufficiency

General Principle Use the smallest amount of contrast material possibleDiscontinue other nephrotoxic medications before the

procedure Allow two to five days between procedures requiringcontrast material

Hydration Oral : 500mL before the procedure and 2,500mL over

the 24 hour after the procedureIntravenous : 0.9% or 0.45% saline 100mL per hour beginning four hours before the procedure andcontinuing for the 24 hours


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Contrast media MRI

MR contrast media differentiate tissue structure. Either increasing signal intensity on T1 weighted image or decrease. Signal intensity in T2 weight image to do sodifferent Gadolinium based contrast media are used eg-diethylene triamine penta acetic acid. 1ml magnavist contain469mg gadiopentetic acid dimeglumine salt in aquoussolution.


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Indication of MRI Contrast

Inter cranial lesion with abnormal Vascularity Abnormality in blood brain barrier Gadopentate enhanced MRI help diagnosis andcharacterization of neoplastic disease

Acoustic neuromaInflammatory diseasesCertain vascular abnormalityDemyelating abnormalityeg multiple sclerosis

Whole Body MRI :Evaluation of suspected hepatic lesionMusculoskeletal lesion. Cardiac MR Imaging


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Contra Indication

It should not administer pts having hypersensitivityRenal failure

Sickle cell anemiaPregnancy


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Contrast agents in ultrasound

Levovist (Schering)Widely used in microbubbles contrast agent

Echovist (Schering) bubbles in a glactose soln but lackingthe palmating acid coatingAlbunex : Air micro bubble used in echocardiographySonvne : Suspension of stabilized sulpher hexafluoridemicrobubbles


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Uses of C/M

It should be used in various places of diagnosticdepartment

IVUBariumMRI

CT AngiographyUltrasound


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Preservation of contrast Media

Proper storage dark place 15 degree C to 30degree CObservation of expiratory date It should be form 2-3 to 5yearsExamination of the C/M solution before used check thecleanness of solution.Crystallization found in solution then the contrast mediawhich is at low tamp is heated upto 80 degree CC/M solution with high viscosity at 37 degree C heatreduces the viscosityRisk of microbial contamination for we should not leave thesolution open for more than 4 hoursResterlization of the C/M solution do not resterlization theopen container Transfer to the sterile container


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Mechanism of contrast media reaction Overdose : Some kinds of patients may be overdose with C/Msmall infants having multiple injection during angio cardio graphyand adults with cardiac renal or hepatic failure may be givenexcessive dose the result of hyperosmaler effect

Chemotoxoicity : Toxic of C/M because of its intrinsic structurethe electrical changes in the particle of the HOCM and of hexaberix (sodium meglumine ioxaglate ) is particular importance in intra coronary use the contains are clinically moretoxic than anions and sodium is more toxic than meglumine tobrain and myocardium the toxicity of intacoronary and high riskof nephrotoxisity cardiovascular disease, seziura


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Anxiety : when C/M reaction as the result of the patients fear and apprehension. The high autonomic nervous system

activity in an anxious patient will be stimulated further whenthe patients experiences the administration of contrast media.When compared with HOCM and LOCM resulted in lessfrequent ECG abnormalities and side effects.

Mechanism of contrast media reaction Contd


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Route of C/M Administration

Intravenous or intra arteriallyManualPower injector e.g. CT, angiographyOrally Barium and TRAZO gastroPer rectumPer vaginal HSGDirects into the sinus


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Safety Precaution

Pts history : Careful history regarding allergy to iodine anycontrast agent any drug or food atomHigh risk of ptsPt with asthma thyroid and cardiac disorder

Pts with chronic seizure , diabetic nephropathy or myelomaHepatic or renal failure impairmentPts with metabolic or hematological disorder Unconscious and semi unconscious ptsPts with history of allergy or a previous reaction to a contrastagentInfantsProper hydration of the pts


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Pts should be will hydrated before the administration of C/M(contrast media)Emergency equipment : emergency resuscitation equipmentand life saving / emergency drug should always be availableduring the procedure and in the observation period following theexposure

Administration of C/MIt is preferable to use glass syringePre testing for hyper sensitivity reaction is mandatoryc/m should always be loaded in the syringe pulling throughthe needle through the rubber cap of the vialOne vial to be uses for one pts only repeated use of a singlevial is not recommended.


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Total dose and volume should be slow

Select appropriate dosing internal to ensure to completeclearance of contrast media from the bodyCareful observation of pts during and after administration

The pts must be carefully observed during and after administration for at least half an hour as serious delayedadverse reaction may occur

Storage and utilization : Should be followed as explained onthe pack. Discard the product if there change in colour


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Advantages of contrast agent

Better visualization tissue contrastBetter diagnosis of disease

Conformation of diagnosisDisadvantage of C/M

Discomfort to the pts for contrast introduction

Chances of various reaction is possibleCost will be additional burden to the patient i.e. costly


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Advances reaction to contrast media

Principles : Adverse reaction can be reduced for appliedgeneral principles of all patients. The smallest amount of

contrast agent possible should be used for each produceallowing at lest 48 hours to elapse between procedure

Adverse reaction to contrast agent range from a mild

inconvenience, such as itching associated hives to a lifethreatening emergency. Renal toxicity is well known adversereaction associated with I.V. contrast material


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Other form of adverse reaction include delayed allergicreaction, anaphylactic reaction and local tissue damage

Previous allergic reaction to contrast material asthma.Pretreatment of patients such risk factor with a corticosteroidand diphenhydramine decreases the chances of allergicreaction. Including anaphylaxis. Renal failure or a possiblelife threatening emergency.

Types of Adverse effects: The incidence of reaction isconsiderably higher the use of ionic contrast media with a

history of previous sever reaction to iodinated contrast media.


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Contrast Media rise to various reaction

Minor reaction : It includes UTCARIA, sneezing , flushing ,nausia vomiting, tinnitus, violent becomes restlessness

usually no treatment is required only to reassure the patientis sufficentsIntermediate Reaction : Development of patches all over thebody, nausia, vomiting and severe. Patient urge to cough bloodpressure raise up a down patients feeds drowsy, patientssweating or feel cold and severingNeed: Treatment but no risk to the patients


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Major Reaction : Bronchospasm, Laryngeal oedema patient pale,sweating thready pulse may loss, consciousness. Respiratoryfailure as the pts can be stop breathing convulsion and coma all

these required prompt and efficient treatment if to survive thepatient

First line treatment of acute reaction to contrast mediaNausia/ vomitingTransient supportive treatmentSevere protected Appropriate antiemetic drugs should beconsidered.

Urticaria :Scattered transient : Supportive treatment and observationScattered protected : Appropriate H1 antihistamine intramuscularlyor intravenously should be considered

Profound : Consider adrenaline (0.1- 03mg) Transmuscularly Inadults 0.01mg/kg


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Bronchospasm :Ox y gen by mark (6-10 1/min)

B2 Agoinst metered dose inhaler (2-3 deepinhalation ) Adrenaline

Normal blood pressureIntramuscular 2mgIn pediatric patients 0.01mg/kg upto 0.3mg max

Decreased blood pressureIntramuscular 0.5ml adrenalineIn pediatric patients 0.01mg/kg intramuscularly

Laryngeal edema :


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Laryngeal edema :Oxygen by mask (6-10 1/min)Intramuscular adrenaline 0.5ml for adults ; repeat as needed.

Hypotension : Isolated hypotensionElevate patients legsOxygen by mask

Intravenous fluid rapidly normal saline or lactated ringerssolutionIf unresponsive adrenaline 0.5ml intramuscularly repeat asneeded

Vagal reaction (hypotension and brody cardia)Elevate patients legs Oxygen by mask ( 6-10 1/min) Atropine 0.6-10mg intravenously repeat if necessary after 3-5

minute to 3mg total (0.04 mg/kg) in adults


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Pedatric patietns give 0.02 mg/kg i.v. max 0.6mg per dose)repeat necessary to 2mg totalIntravenous fluids rapidly normal saline or lactatated ringer solutionGeneralized anaphylactoid reactionCall for resuscitation team

Suction airway as neededElevate patients legs if hypotensive Oxygen by mask ( 6-10 1/min)Intramuscular adrenaline 0.5ml in adults repeat as needed.In pediatric patients 0.01mg/kg to 0.3mg max doseIntravenous fluids (normal saline, lactated ringers)H1 Blocker eg diphendramine 25-50mg intravenously


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Treatment guide line of major reaction

Erythema, uticaria and angio neurotic oedemaIt occur in the form of giant urticaria oedema of the larynaxmay occur causing. Respiratory obstruction and difficulty inrespirationTreatment oxygen should be administrated in all cases25mg phenergan is given intravenously supplemented bythe 0.5ml adriline solution in severe cases 100mg of

hydrocortisone is given.Pulmonary oedma Initially patients is give 02ma inaddition to hydrocortisone 100mg i.v. (intravenous) givenfallowed by 10 to 20ml of aminophylene by slow i.e.

injection


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Hypotensive shock : 02 is given then i.v. drip as soon aspossible prednisolone 20 mg or hydrocortisone 100mg is given

i.v.Cardiac arrest : The hospital emergency team must be callimmediately and the patient ventilated by artificial respiration

with brook airway.The usual additional measure applied to emergency team

applied for administration of adrenaline 1.0ml solution 1%

Sodium bicarbonate drip and 5 to 10ml calcium chloride in dose


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Extravasation of contrast material

Tissue damage is more likely to occur with extravasation of ionic contrast material then with non ionic content agents

Control : Application ice packs and heating pad, andelevation are used to alleviate the symptoms associated withextravasation of contrast material


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Convulsion

With the help of intubations and positive pressure respirationInitially thiopentone tone is administrated by slow i.v. injectionFirst line of emergency drugs and instruments which should beexamination Avil 2ml antihistamine allergic reactionHydrcortin steroid fast action- multipurpose life saving Adrenaline Reduced secretion from bronchial and salivary

glandDiazopam Sedative (anti convulsive)Buscopan Antispasmodic

At i


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AtropineNormal salineDextrose solution

Antihistamine H1 Suitable for injectionBita - 2 against meter dose inhaler i.v. fluids normal saline or ringer solutionSphygmomanometer OneOxygen should be administrated in all casesStethoscopeDrip standEmergency trollyEmergency trolly settingVentilator defibrillator


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Contrast Media and Adverse Effects - Vijay Kumar