Contrast Media Extravasation of Computed Tomography and Magnetic Resonance Imaging: Management Guidelines for the Radiologist

https://doi.org/10.1067/j.cpradiol.2015.08.004Get rights and content

Intravenous contrast administration has been of great importance in diagnostic radiology, but it is not without risks either due to the local, systemic allergic reactions or due to subcutaneous extravasation of contrast media. Subcutaneous contrast medium extravasationis an infrequent, yet a well-recognized complication. However, most incidents are minor and can be managed conservatively, but there are a few cases that require immediate surgical intervention. This article discusses the risks factors, clinical manifestations, and conservative and surgical approaches of subcutaneous contrast media extravasation for both computed tomography and magnetic resonance imaging.

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.

References (24)

  • C.L. Wang et al.

    Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69,657 intravenous injections

    Radiology

    (2007)
  • F.S. Chew

    Extravasation of iodinated contrast medium during CT: Self-assessment module

    Am J Roentgenol

    (2010)
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    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.

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