Radiographic Contrast Media 2021 PDF

RADIOGRAPHIC CONTRAST MEDIA 1 OVERVIEW OF CONTENT • 1) Introduction • 2) Physiology • 3) Mode Of Administration • 4) Classification • 5) Contrast media for XRAY and CT • 6) Ultrasound contrast media • 7) MR contrast agents CONTRAST MEDIA It is a chemical substance of very high or very low atomi...

RADIOGRAPHIC CONTRAST MEDIA 1 OVERVIEW OF CONTENT • 1) Introduction • 2) Physiology • 3) Mode Of Administration • 4) Classification • 5) Contrast media for XRAY and CT • 6) Ultrasound contrast media • 7) MR contrast agents CONTRAST MEDIA It is a chemical substance of very high or very low atomic number or weight, therefor it increase or decrease the density of the organ under examination. • A substance which when introduced into the body will increase the radiographic contrast in an area where it was absent or low before. • Increases atomic number of area injected • Results in a SHORTER scale of subject contrast 3 RADIOGRAPHIC CONTRAST : INFLUENCED BY… • Radiation Quality (KVP) • Film Contrast • Radiographic object (Patient) Atomic Number • Fat = 6.46 • Water = 7.51 • Muscle = 7.64 • Bone = 12.31 4 KVP TYPE OF CONTRAST USED DETERMINES KVP RANGE • BARIUM _______kVp IODINES ________kVp (Ionic / Nonionic Water or Oil) 5 INJECTABLE CONTRAST MEDIA FOR RT 255 PROCEDURES INVASIVE PROCEDURES THE “O-GRAMS” 6 SPECIAL “O-GRAMS” • Venogram • Arthrogram • Sialogram • Myelogram • Arteriogram • Angiogram • Galactogram • Hystersalpingogram…….. etc 7 SPECIAL PROCEDURES ARE INVASIVE ALWAYS GET PATIENT’S HISTORY AND CONSENT BEFORE BEGINNING OR GIVING ANY CONTRAST MEDIA 8 PHYSIOLOGY • Concentration and excretion • 1) >90%: passive glomerular filtration. • 2) 1%: liver and intestine. • Half life: 30-60 minutes. • Do not enter the interior of cells. • Rapidly excreted, over 90% being eliminated by glomerular filteration by kidneys within 12 hrs. • Leaves the body within 24 hours(if normal kidney) and weeks( if diseased kidney). REVIEW OF CONTRAST AGENTS TYPES OF CONTRAST ROUTES OF ADMINSTRATION CHEMICAL COMPONENTS 10 CONTRAST MEDIA CHANGES THE DENSITY OF THE ORGANS Therefore changing the Subject contrast will change the Radiographic contrast and film contrast May need to INCREASE TECHNIQUE FROM SCOUT IMAGE* f/s 11 CONTRAST MEDIA (REVIEW) • Negative contrast • (AIR OR CO2) • Positive contrast • (all others) • Radiolucent • Radiopaque • Low atomic # material • High atomic # material • Black on film • White on film 12 TYPES OF CONTRAST MEDIA • • • • Radiolucentnegative contrast agent x-rays easily penetrate areas- appear ____ on films Negative Contrast Media • Air and gas • complications • emboli-air pockets in vessels • lack of oxygen • • • • Radiopaquepositive contrast agentabsorbs x-rays areas- appear ____ on films Positive Contrast Agents • BARIUM • IODINES Both + & - can be used in same study 13 2 BASIC TYPES OF CONTRAST MATERIAL • BARUIM Z# 56 • NON WATER SOLUABLE • GI TRACT ONLY INGESTED OR RECTALLY • KVP 90 – 120* • IODINE Z# 53 • WATER SOLUABLE • POWDER • LIQUID • INTRAVENOUS OR • Intrathecal • GI TRACT • Also OIL based • KVP BELOW 90* 14 METHODS OF ADMINISTRATION OF CONTRAST MATERIAL • INGESTED • (ORAL) • RETROGRADE • AGAINST NORMAL FLOW • INTRATHECAL • Spinal canal • PARENTERAL (IV, Intrathecal) • Injecting into bloodstream • (anything other than oral) 15 CONTRAST MEDIA FOR SPECIAL PROCEDURES Diagnostic agents that are injected into • Circulatory System, Joint Spaces, Ducts • Body orifices/organs: uterus, breast, salivary & lymph glands 16 BLOOD WORK LAB TESTS TO CHECK FUNCTION OF KIDNEYS PRIOR TO INJECTION OF CONTRAST • • • • • • • WATCH THE UPPER LIMITS BUN = BLOOD UREA NITROGEN Merrills pg 214 range is 8 to 25 pg 242 range is 10 - 20 always check with RAD when level above 20 CREATININE levels range: pg 214 (0.6 - 1.5) pg 242 (0.05 - 1.2) always check with RAD when level above 1.2 Indicates function of kidneys Diseases / dehydration / kidney failure 17 EGFR (NEW TEST) • Estimated • Glomerular • Filtration • Rate More advanced test for • CREATININE levels • Why is this important? 18 VARIOUS WATER-SOLUBLE CONTRAST MEDIA FOR UROGRAPHY AND ANGIOGRAPHY • Both ionic and non-ionic monomers* • are all extracellular contrast media • are excreted unmetabolized by glomerular filtration • Approximately 85-90% of the injected dose is found in urine within the first 6 hours • 95-100% within the first 24 hours 19 MONOMERS* • The ionic monomeric agents are salts that dissociate into two molecules • one anion containing the radiopaque property due to three iodine atoms and one cation without radiopaque properties 20 BARIUM – A REVIEW BARUIM SULFATE NOT USED IN SPECIAL PROCEDURES 21 BARIUM SULFATE • High atomic number Z #? ______ • Not soluble in water • Used to coat the lining of organs • Supplied in different thicknesses • Used • Esophogram, UGI, Small Bowel,Lower GI or BE 22 BA ADVERSE REACTIONS • BARIUM INERT • SUSPENSION MAY CAUSE ALLERGY • OCG TABLETS (IODINE) ALLERGY • AFTER EXAM – MAY SOLIDIFY DIFFICULT TO EVACUATE • INCREASE FLUIDS, MILD LAXATIVE • EXTRAVASATION OF CONTRAST INTO PERITONEUM CONTRAINDICATION: • Integrity of gut wall compromised or GI Perforation. • Previous allergic reactions to barium. • Suspected fistula between oesophagus and lung. 23 EXTRAVASATION OF BA IN ABD 24 INGESTED CONTRAST GASTROGRAFIN OR HYPAQUE • High atomic # • Close to iodine • Water soluble • Similar usage as Barium 25 GASTROGRAFIN ADVERSE REACTIONS • Water soluble, safe in the abdominal cavity • Safe to use if perforation is suspected • Very harmful to the lung tissue • Do not use if aspiration is possible 26 GASTRO – PATHOLOGY PRESENT • Bowel • Obstruction • Note contrast • Seen in kidneys as well 27 IODINE IONIC OR NON IONIC WATER OR OIL BASE 28 IODINE 1) Atomic number 53 2) Atomic weight 127 3) Radioopacity depends on: • iodine concentration of the solution, so dependent on number of iodine atoms in each molecule of the contrast medium. 4) Iodine particle ratio: • the ratio of number of iodine atoms per molecule to the number of osmotically active particles per molecule of solute in solution 5) Iodine is preferred because: • High contrast density due to high atomic number • Allows firm binding to highly variable benzene ring • Low toxicity IODINATED CONTRAST IODINE Z # 53 • WATER BASED • INJECTED • VESSELLS/DUCTS • INGESTED • Organ function/flow • OPEN WOUNDS • OIL BASED • INJECTED • NEVER VESSELLS • ONLY DUCTS • NOT INGESTED • OPEN WOUNDS 30 INJECTION OF IODINE INTO VESSELS • ALWAYS A WATER BASED IODINATED COMPOUND • BOLUS INJECTION • INFUSION DRIP • IONIC VS • NON IONIC • CONTRAST • 50 -70 % CONCENTRATE 31 IODINE WATER BASED CONTRAST • IONIC • LESS $$$ • NON IONIC • MORE $$$ • MORE REACTIONS • LESS REACTIONS 32 CONTRAST MEDIA IODINE is either: IONIC or NON-IONIC • Osmolarity • # Of Particles (Cations + And Anions -) • In Solution Per Kilogram Of Water • High Osmolarity • =more Cations And Anions • Can Upset Homeostasis • Nonionic Have No Charged Particles 33 CONTRAST AGENTS IONIC • High Osmolality (Higher risk of complications) • Diatrizoate sodium (Hypaque) • Iothalamate meglumine (Conray) NON-IONIC • Low Osmolality (Lower risk of complications) • Gadodiamide (Omniscan) • • • • Iodixanol (Visipaque) Iopamidol (Isovue) Iopromide (Ultravist) Ioversol (Optiray) 34 • Less money • More reactions • More money • Less reactions 35 OIL – BASED IODINE CONTAST INSTILLED IN ORGAN – NOT VESSELLS OIL-BASED IODINE CONTRAST MEDIA ARE MADE FROM FATTY ACIDS OF POPPY SEED OIL CONTAINING 48% AND 37% IODINE 36 OIL BASED IODINE • Fatty Acids • Insoluble in water • White on the radiograph = Radiopaque • Uses • Broncography (lungs) • Tear ducts • Salivary glands • Lymphatic system • Hysterrosalpingogram • Galactography (breast ducts) • FAT EMBOLUS IF IT GETS INTO BLOOD VESSEL 37 WHAT CONTRIBUTES TO DISCOMFORT, SIDE EFFECTS, REACTIONS: • VISCOSITY – (thick, sticky) thicker – harder to inject, more heat and vessel irritation (higher = greater viscosity) Warming contrast will help • TOXICITY - (higher = greater viscosity) • MISCIBILITY - easily mixes with blood • OSMOLALITY - is a measure of the total number of particles in solution. 44 HYPOVOLEMIA • basically means low blood volume • Symptoms of hypovolemia may include • cold hands and feet, light headedness, infrequent urination, increased heart rate, and weakness. • Low blood volume can result in multiple organ failure, kidney damage, brain damage, and death • hypovolemia differs from dehydration (which is excessive loss of body water • hypovolemia can lead to dehydration 46 High osmolality of the contrast media is related to adverse reactions. 47 CONTRAST MATERIAL ADVERSE REACTIONS ALWAYS GET PATIENT’S HISTORY BEFORE ANY CONTRAST MEDIA IS GIVEN 48 REACTION CLASSIFICATION • Immediate reactions were defined as those occurring within the department (within one hour) • Delayed as those occurring between the time the patients left the department and up to seven days later 49 GENERAL FACTORS FOR CONTRAST REACTIONS •Nonionic vs ionic Risk Factors Severity of Reactions Renal toxicity • Glucophage Diabetic? • • Screening Creatinine Pretreatment 51 GOOD PATIENT HISTORY • Kidney problems • Diabetes • Heart conditions • Allergies • Asthma • Previous reaction • Current medications • Beta Blockers • Antihypertensive medications • VITAL SIGNS 53 MORE RISK FACTORS FOR CONTRAST REACTION • Older patient age • Allergic Rhinitis, medication or Food Allergy • Cardiovascular disease • WHO are at increased risk of developing a side effect? (2 age classifications?) 56 CONTRAINDICATIONS • • Pregnancy (risk of fetal Thyroid toxicity) • • • Allergic Reaction + Radiation concerns Pathologic Conditions Infection 57 ALLERGIC TO IODINE • General Rule: • No Iodine Contrast will be given • Pre – medication is available • May or may not react if previous iodine given 58 REACTIONS & TREATMENT USUALLY** WITHIN FIRST 5 MINUTES • Nausea & Vomiting & Urticaria • Hypotension (bradycardia) • Hypotension (tachycardia) • Bronchospasm • Anaphylactoid • Seizures • Extravasation 60 CATEGORIES OF ADVERSE REACTIONS MILD CARLTON – PATIENT CARE BOOK: VOL 3 CH. 19 PG 297 OR VOL 4 CH. 20 PG 337 • • • • • nausea, vomiting Uticaria (hives) rash – itching Flush face – feeling of warmth Headace, Chills, Anxiety Diaphoresis Treatment – does not usually get worse Watch patient and reassure (cool cloth on forehead, emesis basin 61 CATAGORIES OF ADVERSE REACTIONS MODERATE CARLTON PT CARE • Hypotension (bradycardia) • Hypertension (tachycardia) • Dyspnea • Bronchospasms /wheezing • Laryngeal Edema TREATMENT: Needs immediate treatment –GET RN/RAD Needs Meds* – (Keep IV line in) could lead to severe reactions 62 CATAGORIES OF ADVERSE REACTIONS SEVERE CARLTON PT CARE • Laryngeal edema • Convulsions • Profound hypotension • Clinically manifested arrhythmias • Unresponsiveness • Cardiopulmonary Arrest PROMPT TREATMENT – CODE BLUE! 63 EXTRAVASATION • Contrast material has seeped outside of vessel • Local redness and swelling • Apply WARM Compress 1st 24 hours • Cool compress for swelling 70 EXTRAVASATION • The act of injecting a drug/contrast into an area other than the vessel (soft tissue) • RTA BOOK: Pharmacology Chapter • Defines as: Discharge or escape of fluid from a vessel into the surrounding tissue that can cause localized vasoconstriction, resulting in sloughing of tissue and tissue necrosis if not reversed with an antidote. 71 EXTRAVASATION OF CONTRAST INTO SOFT TISSUE OF ARM 72 73 CONTRAST LEAKING FROM BLADDER 74 SUMMARY • Delayed side effects persist in IV iodinated contrast media • History of asthma and allergy predisposes patients to increased incidence of adverse reactions • Intravenous iodinated contrast agents are generally safe. • Though the frequency of side effects has fallen significantly since the introduction of nonionic, monomeric contrast agents,however, side effects remain an important issue. • Late adverse reactions were first recognized in the mid-1980s 75 SUMMARY OF CONTRAST REACTIONS • Anaphylactoid reactions may present with • mild symptoms such as skin rash, itching, nasal discharge, nausea, and vomiting • moderate symptoms like facial or laryngeal edema, bronchospasm, dyspnea, tachycardia, and bradycardia • severe symptoms such as life-threatening arrhythmias, hypotension, bronchospasm, laryngeal edema, pulmonary edema, seizure, syncope, and death 76 SUMMARY OF CONTRAST REACTIONS • Nonanaphylactoid reactions are due to the ability of the • • • • contrast media to upset the body homeostasis, especially the blood circulation. Increasing iodine concentration increases the risk of these reactions, which is also affected by the volume and route of administration of contrast. Larger volumes or intra-arterial administration are more likely to produce a reaction. The cardiovascular, respiratory, urinary, gastrointestinal, and nervous systems are most commonly affected by physiologic changes produced by contrast media. The symptoms of nonanaphylactoid reactions are warmth, metallic taste, nausea, vomiting, bradycardia, hypotension, vasovagal reactions, neuropathy, and delayed reactions 77 SCHEDULING CONSIDERATIONS • Diabetics – first • (Insulin= low blood sugar occurs while fasting) • After Nuclear Medicine Tests • (iodine goes to thyroid and will alter results) • Iodine BEFORE Barium • BE before UGI ( IVP before BE) • WATER – OIL - BARIUM 78 ULTRASOUND CONTRAST AGENTS • • A.k.a Echo Enhancing Agents. • These agents Increase The Echogenicity Of Blood, which heightens the tissue contrast & allows better delineation of body cavities. • Consist of Microscopic Gas Filled Bubbles. • Their Extremely High Reflectivity(backscatter) arises from the fact that microbubbles easily change their size, contracting in compression part of the ultrasonic cycle & expanding in the rarefaction part. • Thus They Resonate in the ultrasound beam when there is a mismatch b/w their diameter and ultrasonic wavelength, which occurs for microbubbles in 2 to 7um at usg freq of 2-10 MHz IDEAL ULTRASOUND CONTRAST AGENT • 1) Be injectable by a peripheral vein • 2) Be non toxic • 3) Small enough to pass through pulmonary, cardiac & capillary systems • 4) Stable enough to undergo the shear forces, hydrostatic pressure changes& diameter changes • 5) Half life should be sufficient to allow complete examination • 6) Should require little preparation APPLICATIONS • 1) Evaluating normal, increased or decreased vascularity. • 2) Detecting vascular stenosis & occlusions. • 3) Improving neoplasm detection. • 4) Analysing & characterizing tumour neovascularity. • 5) Differentiating normal variants such as renal column of bertin from neoplasm. • 6) Echocardiography – cardiac cavities, valves, coronary artery & myocardial viability MRI CONTRAST 82 MRI WITH CONTRAST Without With What is the name of the contrast used for MRI ? 83 GADOLINIUM Z# 64 • Once injected, gadolinium accumulates in abnormal tissues of the brain and body. • Provides a greater contrast between normal and abnormal tissues MORE dilute than used for Radiology 84 GADOLINIUM • On its own gadolinium is toxic to the human body, but when coated in a special chelating agent, it is safe to use. • When the chelating agent breaks down prematurely, or the kidneys are unable to excrete the gadolinium from the body, gadolinium poisoning can occur 85 GADOLINIUM SIDE EFFECTS • With impaired kidney function, gadolinium could lead to a serious and potentially fatal disorder called Nephorgenic Systemic Fibrosis. (NSF) • More common conditions associated with exposure includes • impaired kidney function • irritation of blood vessels • facial swelling • skin conditions, including rashes, itching and hives 86 CT CONTRAST • Oral/Rectum • – Barium or Iodine • IV: Iodine • Usually less dilute • than for Radiology 87 CT W CONTRAST 88 CT CONTRAST • CT Scan Contrast Indications • CT Scan Contrast Side Effects • History of tumor, cancer, or surgery • Looking for infection, inflammation • Mild to life-threatening allergic • Evaluating blood vessels • Investigate a finding in a scan done without contrast • • • • • reaction Flushing/redness and hives Shortness of breath Nausea, vomitting Blood clots Dizziness 89