Contrast Media Extravasation of Computed Tomography and Magnetic Resonance Imaging: Management Guidelines for the Radiologist
Introduction
Although administration of intravenous (IV) iodinated contrast has many benefits, there are inherent risks such as local allergic reaction, systemic allergic reaction, and subcutaneous contrast media extravasation. Subcutaneous contrast media extravasation can occur under the supervision of any radiologist, regardless of the level of training or expertise.1
The injuries from subcutaneous contrast media extravasation are minor, resolve spontaneously, and usually they require just follow-up. However, in some instances there are serious complications, which occur because of direct toxicity of the contrast agent or pressure effects, such as compartment syndrome.2
These complications may require immediate surgeries, which sometimes can have a detrimental effect on the patient and health care system because they result in longer hospital stays, thus causing an increase in the patient’s morbidity and mortality.3
This article discusses the risk factors, signs, and guidelines for medical and surgical management of contrast media extravasation as well as steps for prevention.
Section snippets
Definition of Subcutaneous Contrast Media Extravasation
Subcutaneous contrast media extravasation is defined as the inadvertent administration of vesicant fluid into the surrounding healthy tissue instead of the intended vessel.4 A vesicant is an agent that has the capability to cause blistering or tissue necrosis.5
As a result, the extravasation of contrast media typically has a detrimental effect on the surrounding cells and tissues. The incidence of subcutaneous contrast media extravasation varies from 0.1%-0.9% of all contrast-enhanced computed
Patient Population
Extravasation is typically more common in the children, elderly, and patients with a low level of consciousness due their inability to verbalize the pain caused by extravasation.1, 2
Patients with fragile veins such as the elderly, frequent vein punctures, history of radiation therapy in the concerned area, chemotherapy, little muscle mass, and atrophy of the subcutaneous tissue are susceptible to subcutaneous contrast media extravasation.7
Also, the history of peripheral vascular conditions such
Prevention
The direct monitoring of puncture site through palpation during the early stage of puncture is the best preventive measure to detect extravasation. Patients should be made aware of the scanner intercom and instructed to report any symptoms during injection to the CT technologist.
There are several steps that can be taken to avoid a subcutaneous contrast media extravasation. Whenever possible, in a low-osmolality non-ionic-iodinated contrast media if contrast extravasation does occur, tissue
Mild Extravasation
The diagnosis of subcutaneous contrast media extravasation is primarily by clinical and direct physical examination. Sometimes, these are also diagnosed by the absence of contrast media in the images.16 Once this is recognized, the study should be terminated immediately.9
Subcutaneous extravasation injuries are classified as mild, moderate, or severe. According to a recent multicenter review of 771 extravasation injuries by Dykes et al19 the incidences of mild, moderate, and severe extravasation
Follow-Up of Subcutaneous Contrast Media Extravasation
Both proper documentation and patient education are also important in the acute management of the patients as well as the long-term follow-up of the patients.4 Documentation should include the estimated amount, concentration, signs, and location of the subcutaneous contrast media extravasation. It should include a thorough description of the measures taken for intervention and the notification of referring physician if referring physician was notified. Regarding patient education, patients
CT IV Contrast Extravasation Practice Quality Improvement Project
The Society of Abdominal Radiology and American College of Radiology have created a project for practicing radiologists to maintain their cerification and help fellow radiologists from across the country understand and avoid subcutaneous contrast media extravasation by designing a practice quality improvement project. This project monitors the outcome of subcutaneous contrast extravasation of multiple institutions by inputting their findings in the ACR contrast extravasation registry, which is
Conclusion
Even though contrast media extravasation is an infrequent occurrence, radiologists should still be familiar with the common risks factors, signs, and the management of subcutaneous contrast extravasation to prevent serious complications. Although most incidents usually resolve with a conservative approach, the radiologist should know when a surgical consultation is necessary.
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Cited by (18)
Contrast agent extravasation in external jugular vein
2023, American Journal of Emergency MedicineContrast Media Extravasation in Computed Tomography Angiography Using Central Venous Catheter in a Pediatric Patient: A Case Study
2020, Journal of Radiology NursingCitation Excerpt :However, the patient did not report any pain and there was no change in vital signs. Because there is no evidence that aspiration of the ICM, liposuction, or local injection of other agents such corticosteroids or hyaluronidase are able to mitigate the effects of the extravasation, the treatment consisted only in the application of ice at the extravasation site (Cleary et al., 2017; Nicola et al., 2016). Within about an hour, there was partial edema and hyperemia regression.
Dual Verification Reduces Contrast Media Extravasation in Peripheral Intravenous Catheters Lacking Blood Return
2018, Journal of Radiology NursingImplications of iodinated contrast media extravasation in the emergency department
2018, American Journal of Emergency MedicineCitation Excerpt :Iodinated contrast media extravasation has a reported incidence ranging from 0.2 to 1.2% [3-10]. Known risk factors include a distal access vein (hand or foot), smaller IV gauge (22G), older age, and prior radiation or surgery around the site of IV cannulation [3,5,11]. While many extravasation events are self-limited and can be managed conservatively, a small fraction (< 1%) have been known to result in morbid complications such as compartment syndrome or tissue necrosis [3,4].
Gadolinium-Based Contrast Agents: Associated Adverse Reactions
2017, Magnetic Resonance Imaging Clinics of North AmericaCitation Excerpt :GBCA subcutaneous extravasations are rare. The incidence is lower and symptoms are less severe compared with the iodinated contrast agents used for contrast-enhanced CT scans.12 Prince and colleagues10 reported 46 infiltrations in a total of 158,796 gadolinium-based contrast agent–enhanced examinations (3 per 10,000 administrations).
This article was presented at the 100th RSNA meeting as an educational exhibit winning a certificate of merit in Chicago, IL. This is an original review article discussing the contrast media extravasation regarding both CT and MRI.
H.H.A. is a consultant at Bracco Group and RGG Healthcare, he is also a Consulting Author at the Oxford University Press, and received a Research Grant.