DIAGNOSTIC RADIOLOGY

LESSON TWO
 IMAGING CONTRAST

• Many structures in the body remain invisible when X-rays

alone are used and can only be made visible after
administration of a contrast medium.
• Contrast agents are substances used to enhance the
visibility of internal structures in X-ray-based imaging
techniques such as computed tomography, projectional
radiography, and fluoroscopy.
• Contrast agents are typically iodine, or more rarely barium
sulfate.
 Type of contrast materials

• [A] Barium sulphate: for evaluation of the gastrointestinal tract –

• Barium meal
• Barium swallow
• Barium enema
• [B] Water soluble contrast materials
• • Oral use: Gastrographin , ct abdomen, bowel series.
• • IV injection: Omnipaque, visipaque,ultravist, contrapaque,
omniscan.
• Ct abdomen, ct chest, ct angiography, mri brain, spine,
musculoskeletal.
FASTING PRIOR TO INTRAVASCULAR CONTRAST MEDIA ADMINISTRATION

• To decrease the likelihood of vomiting and aspiration, some

practices request that patients fast prior to administration
on intravenous contrast media.
• However, currently used low- and iso-osmolality nonionic
iodinated contrast media used for CT, and gadolinium-
based contrast media (GBCM) used for MRI, have much
lower risk of vomiting compared to the previously used ionic
high-osmolality iodinated contrast media.
 RISKS; EXTRAVASATION;

• The unintentional leakage of vesicant fluids or

medications from the vein into the surrounding tissue.
• Extravasations and severe extravasation injuries are
more common in patients who
• 1) Are uncommunicative,
• 2) Have altered circulation in the injected extremity,
• 3) Have had radiation of the injected extremity, or
• 4) Are injected in the hand, foot, or ankle
 CONT
• Extravasations are also more common in patients injected
with more viscous contrast material.
• The risk of extravasation can be minimized by
1) Using angiocatheters rather than butterfly needles,
2) Performing meticulous intravenous catheter insertion
technique (confirming intravenous location by aspirating
blood through an inserted catheter and flushing the inserted
catheter with a test injection),
• 3) And carefully securing an inserted catheter.
 EVALUATION AND TREATMENT

• health care provider should examine any patient in whom a

contrast-media extravasation occurs; physical examination
should include assessment of tenderness, swelling,
erythema, paresthesia, active and passive range of finger
motion, and perfusion.
• There is no known effective treatment for contrast medium
extravasation, although initial steps should include
elevation of the affected extremity above the level of the
heart, and use of cold or warm compresses. No medical
interventions have been deemed helpful.
 CONT
• Since severe extravasation injuries can develop slowly (up
to hours after an extravasation), all discharged outpatients
should be given clear instructions concerning where and
when to seek additional medical care (including for
worsening pain, development of paresthesia, diminished
range of motion, and new skin ulceration or blistering).
•
• Surgical consultation should be obtained whenever there is
concern for a severe extravasation injury ; this can be
suspected if the patient develops severe pain, progressive
swelling or pain, decreased capillary refill, change in
sensation, worsening active or passive range of motion in
the elbow, wrist, or fingers, or skin ulceration or blistering ;
reliance on an extravasation volume threshold to trigger
surgical consultation is not recommended.
 INITIAL SIGNS AND SYMPTOMS

• Most extravasations are limited to the immediately adjacent

soft tissues (typically the skin and subcutaneous tissues).
• Although most patients complain of initial swelling or
tightness, and/or stinging or burning pain at the site of
extravasation, some experience little or no discomfort.
• On physical examination, the extravasation site may be
edematous, erythematous, and tender.
 REACTIONS TO CONTRAST MEDIA INJECTED INTRAVENOUSLY

• Nausea and vomitingw

• Skin rash
• Dyspnea and tachycardia
• Hypotension and shock
• Cardiac arrest
 CONTRAST MEDIA WARMING

• Contrast media viscosity, like that of many other liquids, is

related to temperature.
• As the temperature of a given contrast medium increases,
there is a concomitant decrease in its dynamic viscosity.
• Therefore, warmed contrast media are less viscous than
room temperature contrast media.
• When a warmed contrast medium is hand- or power-
injected into an intravenous (IV) or intra-arterial (IA)
catheter, there will be less resistance than if the contrast
medium had not been warmed.
 METFORMIN

• Metformin is a biguanide oral anti-hyperglycemic agent

used primarily, but not exclusively, to treat patients with
non-insulin-dependent diabetes mellitus.
• It is available as a generic drug as well as in proprietary
formulations, alone and in combination with other drugs.
• Metformin is thought to act by decreasing hepatic glucose
production and enhancing peripheral glucose uptake as a
result of increased sensitivity of peripheral tissues to
insulin. Only rarely does it cause hypoglycemia.
 CONT
• The most significant adverse effect of metformin therapy is
the potential for the development of metformin associated
lactic acidosis in the susceptible patient.
• Patient mortality in reported cases is about 50%.
 MANAGEMENT

• The management of patients taking metformin should be

guided by the following:
1. Patients taking metformin are not at higher risk than other
patients for post-contrast acute kidney injury.
2. Iodinated contrast is a potential concern for furthering renal
damage in patients with acute kidney injury, and in patients
with severe chronic kidney disease (stage IV or stage V).
3. There have been no reports of lactic acidosis following
intravenous iodinated contrast medium administration in
patients properly selected for metformin administration .
 PATIENT SCREENING PRIOR TO CONTRAST INJECTION

• Assess the patient for risk factors predisposing

them to an adverse reaction to iodine contrast. The
patient or guardian should indicate;
• Previous reactions to iodinated contrast media.
• All severe allergies and reactions (both medications
and food).
• If they are age 60 years or over.
• History of diabetes, kidney disease, solitary kidney, or prior
kidney or other transplant
• History of hypertension requiring medication
• Current use of any metformin-containing medications.
• For women of child-bearing age, if they are or may be
pregnant or if they are breast-feeding.
• The technologist reviews the form and enters the date and
value of the most recent eGFR.
 CRETININE AND eGFR

• Determine whether a serum creatinine and an estimated

glomerular filtration rate (eGFR) acquired within the past 6
weeks are available.
• If this information is not available, the information from the
patient’s screening form is reviewed, focusing on four key
questions to identify patients who are most likely to have
underlying chronic kidney disease:
 CONT
• What is your current age?
• Do you have diabetes?
• Do you have hypertension requiring medication?
• Do you have ANY problems with your kidneys (such as
transplant, single kidney, kidney cancer, kidney surgery, dialysis)?
• If patient is less than 60 years of age and answers NO to
questions 2-4, IV contrast will be administered.
• If a patient is older than 60 years of age and/or answers YES to
any of these questions, an assessment of renal function will be
performed before administering IV contrast.
THANK YOU