CONTRAST MEDIA AND ADVERSE EFFECTS

Varinder singh

INTRODUCTION
Contrast media are those substances which are used to distinguish between organ and tissues, vessels by introducing different methods. Contrast media differs as the attenuation and absorption of radiation. Contrast media 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

HISTORICAL DEVELOPMENT
In 1923 first report of opacification of the urinary tract by renal excretion by retrograde introduction of contrast agent with the use of 10% sodium iodide. This was followed by iodine derivatives of pyridone e.g. of the first contrast media was uroselectian and diodone (diotrast) which were utilized in urography from the 1930. In 1950 that the modern water Soluble contrast media were introduced into clinical radiology. There are all derivatives of triodo benzoic acid, the first being acetrizoate (urokon)

HISTORICAL DEVELOPMENT Contd In 1955 a much safer derivative was reported Diatrizoate. This had on acetamido group. Isomerization of diatrizoate and iothalamate molecule in 1962. The majority of the modern conventional water soluble contrast media was developed. It contains sodium and meglumine. These contrast are Hypertonic with osmolalitis. Hyper osmolality is responsible for many of the adverse effect so low osmolar contrast media was developed which reduce the side effects. Conventional ionic contrast media have a iodine to particle ratio was 3:2. In 1972 a new agent was introduced for radiculography. It was iothalamate molecules to form a dimeriocarmate (Dimer x It was highly toxic so it was discarded Carded. Then Hexabrix (mixed sodium and meglumine salt was developed . This was developed metrizamide (Amipaque), Iopamidol (Niopam) iohexol Omnipaque)

Definition C/M
The contrast media are the salt of organic iodine containing molecules. They are introduced into the body for the purpose of opacifying structure.

Properties of C/M
It must be easily available It must be non toxic / non poisonous Viscosity must be adequate It should not affect locally It must provide adequate contrast for diagnostic purpose It must provide permanent opacification in the radiograph Intrathecal contrast should be missible in CSF Contrast media should be isotonic to blood.

Types of C/M barium Compounds

Barium suspension is made up from pure barium sulphate It is morphological studies of GI tract Barium contrast is used in the form of Ba so4 BASO 4 : White crystalline power Molecular weight = 233 Specific gravity = 4.5 Atomic number = 56 High density barium usually has particle size 5 to 12 micro meter Decreasing the particle size increase viscosity.

Varieties of Barium suppression is used

Proprietary name Baritop 100 E-Z HD Micro opaque DC 100% 250% 100% Density W / V

Micro opaque Powder

Polibar Rapid

76%
100%

Indications

Suspected perforation To distinguish bowel from other structures on CT LOCM is used if aspiration possibly In the case of GI tract of neonates and infants When C/M is likely to enter the lung Possible leakage of contrast media from the GI tact

Advantage

Rapid absorption of LOCM No damage to bowel mucosa Very slow absorption from gut Resulting in good bowel visualization Stable in bowel secretion No adverse effects on the lungs

Complications

Pulmonary oedema Allergic reaction May precipitate in hyper chlorohydric gastric acid

Iodine containing water soluble contrast media

Ionic Non ionic Ionic water saluble c/m (ionic ) (HOCM) a. Urography 60% (Trazograf ) 79% Na/ diagrizoate 52% meglumine diatrizoate Iodine content 292 mg/ml 5.14gm (In 20ml Solution) B. Urografin 76% (Trazograf) 7.4gm (In 20ml Solution) 10% sodium diatrozoate Iodine content 370mg/ml C. Trazogastro (Gastrografin ) ORAL contrast 10% Sodium diatrizoetec 66% meglime diatrizoate Iodine content 370mg/ml

Table 1 Type of Contrast Agents Type Agent High Osmolality Ionic Diatrizoate sodium (Hypaque) Low Osmolality Ionic Loxaglate meglumine (Hexabrix) Nonionic Gadodiamide (Omniscan) Gadoteoridol (Pro Hance) Iodixanol (Visipaque) Iopamidol (Isovue) Iopromide (Ultravist) Ioversol (Optiary)

Table 2 Conditions associated with adverse reactions to contrast Material Preexisting renal insufficiency Previous anaphylactoid reaction to contrast material Asthma Food or medication allergies, or hayfever Multiple medical problem or an underlying disease ( e.g. cardiac disease, preexisting azotemia) Treatment with nephrotoxic agents (e.g. aminoglycosides, nonsteroidal anti-inflammatory agents) Advanced age

Table 3 Methods of Preventing Contrast Material induced renal Insufficiency

General Principle Use the smallest amount of contrast material possible Discontinue other nephrotoxic medications before the procedure Allow two to five days between procedures requiring contrast material Hydration Oral : 500mL before the procedure and 2,500mL over the 24 hour after the procedure Intravenous : 0.9% or 0.45% saline 100mL per hour beginning four hours before the procedure and continuing for the 24 hours

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 so different Gadolinium based contrast media are used egdiethylene triamine penta acetic acid. 1ml magnavist contain 469mg gadiopentetic acid dimeglumine salt in aquous solution.

Indication of MRI Contrast

Inter cranial lesion with abnormal Vascularity Abnormality in blood brain barrier Gadopentate enhanced MRI help diagnosis and characterization of neoplastic disease Acoustic neuroma Inflammatory diseases Certain vascular abnormality Demyelating abnormality eg multiple sclerosis Whole Body MRI : Evaluation of suspected hepatic lesion Musculoskeletal lesion. Cardiac MR Imaging

Contra Indication

It should not administer pts having hypersensitivity Renal failure Sickle cell anemia Pregnancy

Contrast agents in ultrasound

Levovist (Schering) Widely used in microbubbles contrast agent Echovist (Schering) bubbles in a glactose soln but lacking the palmating acid coating Albunex : Air micro bubble used in echocardiography Sonvne : Suspension of stabilized sulpher hexafluoride microbubbles

Uses of C/M

It should be used in various places of diagnostic department IVU Barium MRI CT Angiography Ultrasound

Preservation of contrast Media

Proper storage dark place 15 degree C to 30degree C Observation of expiratory date It should be form 2-3 to 5 years Examination of the C/M solution before used check the cleanness of solution. Crystallization found in solution then the contrast media which is at low tamp is heated upto 80 degree C C/M solution with high viscosity at 37 degree C heat reduces the viscosity Risk of microbial contamination for we should not leave the solution open for more than 4 hours Resterlization of the C/M solution do not resterlization the open container Transfer to the sterile container

Mechanism of contrast media reaction

Overdose : Some kinds of patients may be overdose with C/M small infants having multiple injection during angio cardio graphy and adults with cardiac renal or hepatic failure may be given excessive dose the result of hyperosmaler effect Chemotoxoicity : Toxic of C/M because of its intrinsic structure the 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 more toxic than anions and sodium is more toxic than meglumine to brain and myocardium the toxicity of intacoronary and high risk of nephrotoxisity cardiovascular disease, seziura

Mechanism of contrast media reaction Contd

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 when the patients experiences the administration of contrast media. When compared with HOCM and LOCM resulted in less frequent ECG abnormalities and side effects.

Route of C/M Administration

Intravenous or intra arterially Manual Power injector e.g. CT, angiography Orally Barium and TRAZO gastro Per rectum Per vaginal HSG Directs into the sinus

Safety Precaution
Pts history : Careful history regarding allergy to iodine any contrast agent any drug or food atom High risk of pts Pt with asthma thyroid and cardiac disorder Pts with chronic seizure , diabetic nephropathy or myeloma Hepatic or renal failure impairment Pts with metabolic or hematological disorder Unconscious and semi unconscious pts Pts with history of allergy or a previous reaction to a contrast agent Infants Proper hydration of the pts

Pts should be will hydrated before the administration of C/M (contrast media) Emergency equipment : emergency resuscitation equipment and life saving / emergency drug should always be available during the procedure and in the observation period following the exposure Administration of C/M It is preferable to use glass syringe Pre testing for hyper sensitivity reaction is mandatory c/m should always be loaded in the syringe pulling through the needle through the rubber cap of the vial One vial to be uses for one pts only repeated use of a single vial is not recommended.

Total dose and volume should be slow Select appropriate dosing internal to ensure to complete clearance of contrast media from the body Careful 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 delayed adverse reaction may occur Storage and utilization : Should be followed as explained on the pack. Discard the product if there change in colour

Advantages of contrast agent

Better visualization tissue contrast Better diagnosis of disease Conformation of diagnosis Disadvantage of C/M Discomfort to the pts for contrast introduction Chances of various reaction is possible Cost will be additional burden to the patient i.e. costly

Advances reaction to contrast media

Principles : Adverse reaction can be reduced for applied general principles of all patients. The smallest amount of contrast agent possible should be used for each produce allowing 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 life threatening emergency. Renal toxicity is well known adverse reaction associated with I.V. contrast material

Other form of adverse reaction include delayed allergic reaction, anaphylactic reaction and local tissue damage Previous allergic reaction to contrast material asthma. Pretreatment of patients such risk factor with a corticosteroid and diphenhydramine decreases the chances of allergic reaction. Including anaphylaxis. Renal failure or a possible life threatening emergency. Types of Adverse effects: The incidence of reaction is considerably higher the use of ionic contrast media with a history of previous sever reaction to iodinated contrast media.

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 patient is sufficents Intermediate Reaction : Development of patches all over the body, nausia, vomiting and severe. Patient urge to cough blood pressure raise up a down patients feeds drowsy, patients sweating or feel cold and severing Need: Treatment but no risk to the patients

Major Reaction : Bronchospasm, Laryngeal oedema patient pale, sweating thready pulse may loss, consciousness. Respiratory failure as the pts can be stop breathing convulsion and coma all these required prompt and efficient treatment if to survive the patient First line treatment of acute reaction to contrast media Nausia/ vomiting Transient supportive treatment Severe protected Appropriate antiemetic drugs should be considered. Urticaria : Scattered transient : Supportive treatment and observation Scattered protected : Appropriate H1 antihistamine intramuscularly or intravenously should be considered Profound : Consider adrenaline (0.1- 03mg) Transmuscularly In adults 0.01mg/kg

Bronchospasm : Ox y gen by mark (6-10 1/min) B2 Agoinst metered dose inhaler (2-3 deep inhalation ) Adrenaline Normal blood pressure Intramuscular 2mg In pediatric patients 0.01mg/kg upto 0.3mg max Decreased blood pressure Intramuscular 0.5ml adrenaline In pediatric patients 0.01mg/kg intramuscularly

Laryngeal edema : Oxygen by mask (6-10 1/min) Intramuscular adrenaline 0.5ml for adults ; repeat as needed. Hypotension : Isolated hypotension Elevate patients legs Oxygen by mask Intravenous fluid rapidly normal saline or lactated ringers solution If unresponsive adrenaline 0.5ml intramuscularly repeat as needed 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

Pedatric patietns give 0.02 mg/kg i.v. max 0.6mg per dose) repeat necessary to 2mg total Intravenous fluids rapidly normal saline or lactatated ringer solution Generalized anaphylactoid reaction Call for resuscitation team Suction airway as needed Elevate 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 dose Intravenous fluids (normal saline, lactated ringers) H1 Blocker eg diphendramine 25-50mg intravenously

Treatment guide line of major reaction

Erythema, uticaria and angio neurotic oedema It occur in the form of giant urticaria oedema of the larynax may occur causing. Respiratory obstruction and difficulty in respiration Treatment oxygen should be administrated in all cases 25mg phenergan is given intravenously supplemented by the 0.5ml adriline solution in severe cases 100mg of hydrocortisone is given. Pulmonary oedma Initially patients is give 02ma in addition to hydrocortisone 100mg i.v. (intravenous) given fallowed by 10 to 20ml of aminophylene by slow i.e. injection

Hypotensive shock : 02 is given then i.v. drip as soon as possible prednisolone 20 mg or hydrocortisone 100mg is given i.v. Cardiac arrest : The hospital emergency team must be call immediately 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

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, and elevation are used to alleviate the symptoms associated with extravasation of contrast material

Convulsion

With the help of intubations and positive pressure respiration Initially thiopentone tone is administrated by slow i.v. injection. First line of emergency drugs and instruments which should be examination Avil 2ml antihistamine allergic reaction Hydrcortin steroid fast action- multipurpose life saving Adrenaline Reduced secretion from bronchial and salivary gland Diazopam Sedative (anti convulsive) Buscopan Antispasmodic

Atropine Normal saline Dextrose solution Antihistamine H1 Suitable for injection Bita - 2 against meter dose inhaler i.v. fluids normal saline or ringer solution Sphygmomanometer One Oxygen should be administrated in all cases Stethoscope Drip stand Emergency trolly Emergency trolly setting Ventilator defibrillator