ESUR guidelines on Contrast Media

Type of injuries

• Most injuries are minor.

• Severe injuries include skin ulceration, soft-tissue necrosis, and compartment syndrome.

RISK FACTORS

Technique-related

• Use of a power injector.
• Less optimal injection sites including lower limb and small distal veins.
• Large volume of contrast medium.
• High-osmolar contrast media.
• High-viscosity contrast media.

Patient-related

• Inability to communicate.
• Fragile or damaged veins.
• Arterial insufficiency.
• Compromised lymphatic and/or venous drainage.
• Obesity.

To reduce the risk

• Intravenous technique should always be meticulous using an appropriate sized plastic cannula placed in a suitable vein to handle the flow rate used during the injection.
• Consider use of cannulas with sideholes.
• Test injection with normal saline.
• Use non-ionic iodine-based contrast medium.

Management

• Documenting the extravasation with a plain radiograph, CT scan or MR scan of the affected region may be helpful.
• Conservative management is adequate in most cases.
  • Limb elevation
  • Ice packs
  • Careful monitoring.

• If a serious injury is suspected, seek the advice of a surgeon.

Pulmonary adverse effects

• Bronchospasm.
• Increased pulmonary vascular resistance.
• Pulmonary edema.

Patients at high risk

• History of asthma.
• History of pulmonary hypertension.
• Incipient cardiac failure.

To reduce the risk of pulmonary adverse effects

• Use low- or iso-osmolar contrast media.
• Avoid large doses of contrast media.

Iodine-based contrast media

Gadolinium-based contrast agents

Pregnancy

a)In exceptional circumstances, when radiographic examination is essential, iodine-based contrast media may be given to the pregnant female.

b) Following administration of iodine-based contrast media to the mother during pregnancy, thyroid function should be checked in the neonate during the first week.

a) When there is a very strong indication for enhanced MR, the smallest possible dose of a macrocyclic gadolinium contrast agent (see A.3.2. Agents with lowest risk of NSF) may be given to the pregnant female.

b) Following administration of gadolinium-based agents to the mother during pregnancy, no neonatal tests are necessary.

Lactation

Breast feeding may be continued normally when iodine-based contrast media is given to the mother.

Breast feeding may be continued normally when macrocyclic gadolinium-based contrast agents are given to the mother.

Pregnant or lactating mother with renal impairment

See renal adverse reactions (B.2.). No additional precautions are necessary for the fetus or neonate.

Do not administer gadolinium-based contrast agents.

General recommendation

• Be aware of the patient’s drug history.
• Keep a proper record of the contrast agent injection (time, dose, name).
• Do not mix contrast agents with other drugs in tubes and syringes.

Drugs needing special attention

Metformin

Refer to renal adverse reactions section (B.4.).

Nephrotoxic drugs

Cyclosporine

Cisplatin

Aminoglycosides

Non steroid anti-inflammatory drugs

Stopping nephrotoxic drugs before administering contrast agents is not generally recommended.

ß-blocker

ß-blockers may impair the management of bronchospasm and the response to adrenaline.

Interleukin-2

Refer to late adverse reactions section (A.2.).

Non-emergency biochemical assays

Recommendation

• Preferably collect urine and blood before administration of a contrast agent.
• In patients with normal renal function, blood can be collected 4 hours after contrast agent administration if necessary.
• In patients with reduced renal function (eGFR < 45 ml/min/1.73 m²), blood collection should be delayed for as long as possible after contrast agent administration.
• Urine collection should not be done within 24 hours of administration of a contrast agent.
• The effects of the contrast agents on the analyses may differ dependent on which analytic method is used.

Isotope studies and/or treatment

Thyroid

• Patients undergoing therapy with radioactive iodine should not have received iodine-based contrast medium for at least 2 months before treatment.
• Isotope imaging of the thyroid should be avoided for 2 months after iodine-based contrast medium injection.

Bone, red blood cell labelling

• Avoid iodine-based contrast medium injection for at least 24 hours before the isotope study.

Statements

• Ultrasound contrast agents are generally safe.
• Clinical evidence of ultrasound contrast agent related events in critically ill patients and patients with acute coronary disease is limited.

Contraindication

• Avoid ultrasound contrast agents in the 24 hours before extracorporeal shock wave treatment.

Type and severity of reactions

• The majority of reactions are minor (e.g. headache, nausea, sensation of heat, altered taste) and self-resolving.
• More severe acute reactions are rare and are similar to those after iodine- and gadolinium-based agents (see A.1.).

To reduce the risk

• Check for intolerance to any of the components of the contrast agent.
• Use the lowest level of acoustic output and shortest scanning time to allow a diagnostic examination.

Treatment

• If a serious event occurs – see General adverse reaction section A.1.2.

Statements

Recommended action

Contraindications

Integrity of gut wall compromised

• Use iodine-based water-soluble contrast media.
• In neonates and patients at risk of leakage into mediastinum and/or lungs use low- or iso-osmolar contrast media.

Previous allergic reactions to barium products

Use iodine-based water-soluble contrast media and be prepared to treat a reaction.

Cautions

Bowel strictures

Use only small amounts.

Extensive colitis

Avoid barium enemas.

Complications

Reduced bowel motility

Encourage fluid intake.

Venous intravasation

• Early identification and careful observation.
• Antibiotics and intravenous fluids.
• Emergency treatment may be needed.

Aspiration

• Bronchoscopic removal for large amounts.
• Chest physiotherapy.
• Antibiotics.