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Intravenous contrast media: Management and prevention of adverse reactions

Intravenous contrast media: Management and prevention of adverse reactions. Zulmarie Roig, MD NSMC Department of Radiology. Goals. Review some of the commonly used contrast agents for CT and MRI Study the different types of adverse reactions

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Intravenous contrast media: Management and prevention of adverse reactions

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  1. Intravenous contrast media:Management and prevention of adverse reactions Zulmarie Roig, MD NSMC Department of Radiology

  2. Goals • Review some of the commonly used contrast agents for CT and MRI • Study the different types of adverse reactions • Discuss how to manage and treat an adverse reaction • Review pretreatment protocol, for patients with known previous contrast reaction/allergy

  3. Intravenous contrast • Enhance and improve the visibility of internal organs/body structures • Improve the imaging quality • CT • Clear iodine compound • Ionic • Non-ionic • Bound to organic compound • Fewer side effects: do not dissociate into component molecules

  4. Intravenous contrast • Ionic • Higher osmolality • More side effects • Examples: • Hypaque 50 (osmolality 1550) • Isopaque 370 (2100)

  5. Intravenous contrast • Nonionic • Lower osmolality • Less side effects • Toxicity decreases as osmolality approaches the osmolality of serum • Examples: • Isovue 370 • Omnipaque 350 • Ultravist 370 • Visipaque 320

  6. Intravenous contrast

  7. Intravenous contrast • MRI • Classified by chemical composition, magnetic properties, and biodistribution • Gadolinium based : paramagnetic • Iron oxide: superparamagnetic • Iron platinum: superparamagnetic • Manganese: paramagnetic

  8. Intravenous contrast • MRI • Gadolinium (Gd): Paramagnetic • Most commonly used • Chelated form- bind to an organic compound • low as 0.1 mmol per kg body mass • Extracellular fluid agents • Ionic (Magnevist) • Neutral (Gadavist) • Blood pool agents • Albumin-binding (Ablavar) • Organ specific agent • Primovist, Multihance- hepatobiliary agents

  9. Contrast adverse reactions • Mechanism • Direct release of histamine • Contrast molecule causes an effect on antigen binding sites on IgE of mast cells (4%) • Severity of reaction-quantity of circulating IgE and mast cells • Or due to direct contact with blood vessel endothelium , leads to activation of factor XII -> kallikrein ->bradykinin -> prostaglandins -> leucotrines (histamine like effect)

  10. Contrast adverse reactions • Mild • Self limited • Moderate • Require treatment • Not immediate life threatening • Severe • Life threatening

  11. Contrast adverse reactions • Mild • Nausea/vomiting • Cough • Warmth • HA • Dizziness • Altered taste • Itching • Chills, sweats • Rash, hives • Nasal stuffiness • Swelling face/eyes

  12. Contrast adverse reactions • Moderate • Tachycardia / bradycardia • Hypertension • Hypotension • Pronounce cutaneous reaction • Dyspnea • Wheezing/ bronchospasm • Laryngeal edema

  13. Contrast adverse reactions • Severe • Severe/progressive laryngeal edema • Arrhythmia • Profound hypotension • Seizures • Cardiac arrest • Anaphylaxis • Occurs soon after injection

  14. Contrast adverse reactions • Incidence of allergic reaction to CT contrast: • Mild : 0.7 - 3% • Moderate • 1 in 250 pt (0.4%) • Severe, life threatening • Uncommon • 1 in 2500 (0.04%) • MRI contrast: • 0.07-2.4%

  15. Contrast adverse reactions • Delayed reaction • Occur 3 hr to 7 days • Incidence: 0.5 – 9% • Higher rate; nonionic low osmolar agents • Cutaneous reactions , most common • Nausea/vomiting, HA

  16. Management and treatment of reactions • Call for assistance • Evaluate patient: Look and talk to the patient • Vital signs • Quickly evaluate • ? hives, edema, SOB, coughing, wheezing, inspiratory stridor

  17. Treatment • Mild and moderate reactions • Mild • Support • Medication • Diphenhydramine (Benadryl ) 25-50 mg PO or IV • Moderate • O2 • IV fluids • Hx of asthma or bronchospasm- albuterol inhaler • Benadryl 25 mg IV • corticosteroids

  18. Treatment • Severe reactions • If anaphylaxis • Stop contrast injection, saline • Secure airway • Restore BP • IV fluids • Laying patient flat, raising feet

  19. Treatment • Severe reactions • O2 • Antihistamine (Benadryl 25 mg IV, chlorpheniramine 10-20 mg IV) • Corticosteroid (hydrocortisone 100-300 mg IV) • EpiPen

  20. Medications • Epinephrine • IV: 0.5 to 1 ml (50 to 100 mcg) of the 10 cc bristojet 1:10,000 concentration • Do not use the 1:1000 strength IV • SQ: 0.3 ml (300 mcg) of the 1:1000 concentration (1ml vial)

  21. Medications • Albuterol inhaler • Atropine – treat bradycardia • 0.6-1 mg IV • Diphenhydramine • 25-50 mg IV or IM • Clonidine- hypertensive crisis • 200 mcg (0.2 mg) PO

  22. Pre-medication • Indicated in patients with prior allergy / reaction • Does not eliminate risk for breakthrough reaction • Breakthrough reaction – 10 % premed patients • Breakthrough reaction: reaction that occurs after IV contrast in patient’s premedicated with corticosteroids.

  23. Pre-medication • Risk factors: • Severe allergy to any substance • Allergy to 4 or > allergens • Drug allergy • Chronic use of corticosteroids • Change contrast media, another low osmolar agent • Schedule studies at hospital (not out patient centers)

  24. Pre-medication • Severity signs, and symptoms = index reaction • Mild index of reaction – low risk of developing a severe breakthrough reaction • Pre-medicated patients + low osmolar agents: • 88 % pt with prior mild reactions do not repeat breakthrough • Moderate /severe index: • High risk for a second moderate or severe reaction (42%). • Risk of an adverse reaction to MRI contrast: 8 times higher if prior reaction

  25. Pre-medication • Oral regimen: • Prednisone 50 mg PO, 13, 7, and 1 hour prior to exam/ or Methylprednisolone Sodium Succinate (Solu-Medrol) 32 mg PO 12, and 2 hr prior • Diphenhydramine (Benadryl) 50 mg PO 1 hour prior to study • IV regimen: • Hydrocortisone 200 mg IV 13,7, and 1 hr before procedure • Benadryl 50 mg IM or IV, I hr before • Urgent IV protocol: • Hydrocortisone 200 mg 4 , 1 hr prior / or Solu-Medrol 120 mg 1 hr before • Benadryl 50 mg IM or IV , 1 hr prior

  26. References • ACR Manual of Contrast Media, Version 8, 2012 • Recognition and treatment of acute contrast reactions, Applied Radiology Vol 38, #12, 12/2009. • Frequently Asked Questions: Iodinated Contrast Agents, Radiographics, 2004; 24:S3-S10 • Repeat contrast Medium Reactions in Premedicated patients, Radiology: Vol 253:Number 2, 2009 • Delayed Adverse Reaction to Contrast enhanced CT, Radiology: Vol. 255: Num 3-June 2010.

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