Published Aug 2000
Revised Jan 2005

Radiographic Contrast Material
Download to your Palm view with free iSilo viewer
General
Nonionic vs ionic
Risk Factors
Severity of Reactions
Renal toxicity
Glucophage
Screening Creatinine
Pregnancy

  Treatment
References
Disclaimer
General (top)
  • > 10 million diagnostic procedures / year
  • Conventional ionic contrast reactions - 10%
  • 1 in 1000 severe

Contrast Reactions

Contrast Myths

  • not caused by iodine
  • not related to shellfish
  • not true allergy (no drug-antibody)
  • mechanism remains unknown

Anaphylactoid (idiosyncratic)

  • unpredictable
  • dose independent
  • prevalence 1-2% (0.04 - 0.22% severe)
  • fatal 1 in 75,000

Chemotoxic

  • predictable
  • dose dependent
  • due to osmolality or ionic composition

Nonionic vs Ionic (top)

  • Contrast reactions decreased 5 fold
  • Fatalities unchanged

Risk Factors (top)

Previous contrast reaction either moderate or severe

  • asthma
  • allergy history requiring medical treatment
  • pretesting poor predictor of reaction

Repeat Reactions, ionic

  • bronchospasm 40% to facial edema 70%
  • decrease to 6 - 9% with pretreatment
  • decrease to 0.6% with pretreatment and switch to nonionic

Late Reactions

  • 1 hr to 1 week following contrast injection
  • Headache, myalgias, fever, skin rections
  • Risk Factors
    • Previous contrast reaction
    • Interleukin-2 treatment
  • usually self-limited, treat severe reactions with steroids

Severity of Reactions (top)

Minor

  • Nausea & vomiting
  • Urticaria
  • Pruritis
  • Diaphoresis

Moderate

  • Faintness
  • Facial edema
  • Laryngeal edema
  • Bronchospasm

Severe

  • Pulmonary edema
  • Respiratory arrest
  • Cardiac arrest
  • Seizures

Renal Toxicity (increased serum creatinine by more than 25% or > 0.5 mg%) (top)

  • 2-7%
  • Risk Factors
    • 5 - 10 fold increase with pre-existing renal insufficiency (increased creatinine)
    • Dehydration
    • CHF
    • Age > 70
    • Taking nephrotoxic drugs (nonsteroidal inflammatory agents, gentomycin etc.)
  • direct relationship between serum creatinine and likelihood nephrotoxicity
  • Hydrate 100 ml/hr Normal saline 4 hrs prior to procedure, continue for 24 hours
  • Those on hemodialysis do not need extra seesions or dialysis immediately following contrast administration

Metformin (Glucophage) (top)

  • oral diabetic agent
  • patients with renal insufficiency may develop lactic acidosis
  • withhold drug for 48 hrs after contrast administration in all patients taking this drug

Screening Creatinine (top)

Which patients need screening creatinine?
Consider if patient has one of the following risk factors

  • Known renal insufficiency
  • Diabetes mellitus
  • Lasix or nephrotoxic drugs
  • Solitary kidney

Study: 2034 outpatients, 66 (3.2%) had elevated creatinine (>2.0) One or more risk factors in 64. Two patients (0.1%) with renal insufficiency had no risk factors.

Calculate Creatinine Clearance

Pregnancy (top)
  • Discard breast milk for 24 hours following contrast administration

Treatment Contrast Reactions (top)

Nausea & Vomiting (top)

  • usually self-limited
  • protracted: Prochlorperazine (Compazine) 5-10 mg IM

Urticaria

  • Diphenhydramine (Benadryl) 25 - 50 mg IM, caution: drowsiness
  • add Cimetidine (Tagamet) 300 mg in 20 ml, IV slowly

Hypotension

     bradycardia (Vasovagal) (top)

  • elevate legs (infuses 700 ml)
  • IV fluid (normal saline)
  • O2 3 L/min
  • atropine 0.6 mg IV push, repeat up to 3 mg total

     tachycardia (top)

  • elevate legs
  • IV fluid (normal saline) may require > 1 Liter
  • O2 3 L/min

Bronchospasm or laryngeal edema (top)

  • O2 3 L/min
  • Epinephrine 1:1000 (0.1 - 0.2 ml subq) or 1:10,000 1 ml IV over 3 min
  • B2 agonist 2 -3 puffs
    • albuterol (Proventyl)
    • metaproterenol (Alupent)
    • terbutaline (Brethaine)

Anaphylactoid (top)

  • O2 3 L/min
  • IV normal saline
  • Epinephrine
  • Benadryl 25 - 50 mg IV
  • Tagamet 300 mg in 20 ml IV slowly
  • Solumedrol 1 gm IV
    • Note: if patient taking beta blocker
    • glucagon 1 - 5 mg IV bolus followed by infusion 5-15 ug/min or
    • isoproternol 1:5000 (0.2 mg/ml)
      • IV 0.5 - 1.0 ml diluted in 10 ml
      • 1 mg increments

Seizures (top)

  • protect airway
  • Diazepam (valium) 5 mg IV slowly

Suspected pheochromocytoma (top)

  • phentolamine (Regitine) 5.0 ml (5 mg) IV bolus

Extravasation (top)

Initial

  • Elevate extremity
  • Ice pack 3x day
  • Observe for 2-4 hours if volume > 5ml

Surgical Consultation

  • ionic > 30 ml
  • nonionic > 100 ml
  • skin blistering
  • altered tissue perfusion
  • increasing pain after 2-4 hours
  • change in sensation distal to site of extravasation

Pretreatment

Reduces minor reactions but probably does not reduce life-threatening reactions

Emergency

  • hydrocortisone 200 mg IV every 4 hrs until procedure
  • Benadryl 50 mg IM 1 hr before procedure

Routine

  • Benadryl 50 mg IM or PO 1 hr before procedure
  • Prednisone 50 mg PO 13, 7, 1 hr before procedure
  • Observe patient at least 30 minutes following injection
  • N-Acetylcysteine 600 or 1,200 mg PO BID the day before and day of the procedure or 150 mg/kg IV over .5 hr or 50 mg/kg IV over 4 hr

References (top)

Guidelines for Contrast Media from the European Society of Urogenital Radiology

Thomsen HS. Guidelines for contrast media from the European society of urogenital radiology. AJR 2003; 181:1463-71.
[Related Records][Full text]

Bush WH, Swanson DP. Acute reactions to intravascular contrast media: types, risk factors, recognition, and specific treatment. AJR 1991; 157:1153-1161.
[Related Records]

Tippins RB, Torres WE, Baumgartner BR, Baumgarten DA. Are screening serum creatinine levels necessary prior to outpatient CT examinations? Radiology 2000; 216:481-484.
[Related Records]

Katayama H, Yamaguchi K, Kozuka T, et al. Adverse reactions to ionic and nonionic contrast media. A report from the Japanese Committee on the Safety of Contrast Media. Radiology 1990; 175:621-628.
[Related Records]

Cohan RH, Ellis JH, Garner WL. Extravasation of radiographic contrast material: recognition, prevention, and treatment. Radiology 1996; 200:593-604.
[Related Records]

McClennan BL. Adverse reactions to iodinated contrast media. Recognition and response. Invest Radiol 1994; 29 Suppl 1:S46-50.
[Related Records]

Ashley JB,Millward SF. Contrast agent-induced nephropathy: a simple way to identify patients with preexisting renal insufficiency. AJR 2003; 181:451-4.
[Related Records][Full text]
Bettmann MA. Frequently asked questions: iodinated contrast agents. Radiographics 2004; 24 Suppl 1:S3-10.
[Related Records][Full text]

Disclaimer:

Information provided is not intended to be medical or technical advice. The information given at this site is for educational purposes only and is not sufficient for medical decisions. I disclaim any liability for the acts of any physicians or any other individual who receives any information on any medical procedure through this web site. I accept no legal responsibility for any injury and/or damage to persons or property from any of the suggestions or material discussed herein. Practioners should read pharmaceutical manufacturers' package inserts for instructions about dosages, contraindications, and other drug-related information.