Chamaree Chuapetcharasopon, MD,MBA [email protected] 26 October 2019 8 November 1895 DISCLOSURE
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Contrast media
การบรรยายจะครอบคลุม 1. Contrast Media ชนิดต่างๆที่ใช้ใน Diagnostic Radiology 2. ความปลอดภัยและปัญหาของการใช้ Contrast ชนิดต่างๆ Contrast media
Patient Selection and Preparation Strategies 1) ควรแน่ใจว่าการให้การตรวจวินิจฉัยด้วย Contrast Media ในครั้ง นั้นๆ appropriate สาหรับผู้ป่วยรายนั้นๆและมี indication ที่เหมหมะสม 2) คานึงถึงความเหมสี่ยงของการการเหมกิดปฏิกริยาต่อ Contrast Media และประโยชน์ที่จะได้จากการตรวจ 3) มีการตรวจอื่นทดแทนได้หรือไม่ 4) เหมพื่อให้เหมกิดการวินิจฉัยและการรักษาที่ถูกต้องและมีประโยชน์ 5) ต้องมีความพร้อมที่จะให้การดูแลรักษาปฏิกิริยาที่อาจจะเหมกิดขึ้น Contrast media
สาหรับ บุคลากรที่เหมกี่ยวข้อง ควรติดตาม ACR Manual on Contrast Media เหมป็นระยะๆ มีการ update เหมป็นประจ า เหมกี่ยวกับ Iodinated Water Soluble Contrast Media และ MRI Contrast Media ปี 2017 เหมพิ่มเหมรื่อง Ultrasound Contrast Media Download free ที่ www.acr.org https://www.acr.org/Clinical-Resources/Contrast- Manual
Contrast media
Ultrasound X ray source modalities (General Radiology, Fluoroscopy, CT, Angiogram) (Intravenous, Intra- arterial, Intra-articular, Intra-osseous route) MRI Contrast media
Ultrasound Contrast Media Commercial currently available are Optison (GE Healthcare, Chalfont St Giles, UK), Definity (Lantheus Medical Imaging, North Billerica, MA, USA), SonoVue (Bracco, Milan, Italy) (Lumason) Sonazoid (GE Healthcare, Chalfont St Giles, UK). Echovist/Levovist (Bayer Schering Pharma AG) Contrast media (Ultrasound)
The main constituent of an ultrasound contrast agent is gas-filled microbubbles. A US contrast agent is excreted via the lung after the destruction of the microbubbles; hence, it is not nephrotoxic. It does not contain iodine. Although the US contrast agent is very safe, it can be regarded as a foreign material by the immune system; therefore, a hypersensitivity reaction is possible. The incidence of a severe hypersensitivity reaction was reported in about 0.002% in large scale abdominal application studies. The overall reported incidence of the hypersensitivity reaction was similar to that of the use of a gadolinium chelate contrast agent in MRI.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4282229/pdf/usg-14034.pdf Contrast media(Ultrasound) Contraindications acute coronary syndrome or clinically unstable ischemic cardiac disease, right-to left shunts, severe pulmonary hypertension, uncontrolled systemic hypertension, and adult respiratory distress syndrome The European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB) guidelines have recommended caution as damage to the microvessel can be clinically harmful to the eye or the brain has not been evaluated in pregnant women, in women who are breast- feeding, or in patients who are younger than 18 years of age, should be avoided in these patients Contrast media(Ultrasound)
http://icus-society.org/
Contrast media
X ray source modalities (General Radiology, Fluoroscopy, CT, Angiogram) (Intravenous, Intra- arterial, Intra-articular, Intra-osseous route) Iodinated Contrast Media A little bit of history 1896 AD Contrast media
December 1934 Angiography In 1928 The Portuguese physician and neurologist Egas Moniz at the University of Lisbon to provide contrasted x-ray cerebral angiography. Received a Nobel Prize in Physiology or Medicine, in 1949 Reynaldo Cid dos Santos performed the first aortogram in the same city in 1929. Heart catheterization was first performed in 1929 when the German physician Werner Forssmann inserted a plastic tube in his cubital vein and guided it to the right chamber of the heart. He took an x-ray to prove his success and published it on November 5, 1929. Received Nobel Prize in Medicine in 1956. Egas Moniz (1874-1955)
Reynaldo Cid dos Santos (1880-1970)
Werner Forssmann (1904-1979) Dr. Sven-Ivar Seldinger (1921-1998), a Swedish radiologist
Contrast media
Intravascular Iodinated Contrast Media ชนิดของ CM แบ่งตามการแตกตัวในสารละลาย แบ่งตามจานวน Benzene ring Contrast media
1.แบ่งตามการแตกตัวในสารละลาย แตกตัวเหมป็น anion ประจุลบ และ cation ประจุบวก (ionic) ไม่แตกตัว ( nonionic)
2. แบ่งตามจานวน Benzene ring 1 ring = monomer = 3 iodine atoms 2 rings = dimer = 6 iodine atoms A + - A 0 I I I I
C B C B
I I Ionic monomer Nonionic monomer + - 0
Ionic dimer Nonionic dimer Contrast media Class Iodine content Osmolality (mg/ml) (mOsm/kgH2O) Blood 290 High osmolality (ionic, monomeric) Urografin 30% 146 710 45% 219 1050 60% 292 1500 76% 370 2100 Angiografin 306 1530 Contrast media Class Iodine content Osmolality (mg/ml) (mOsm/KgH2O) Blood 290
Low osmolality (ionic, dimeric) Hexabrix (Ioxaglate) 320 602 Contrast media Class Iodine content Osmolality (mg/ml) (mOsm/KgH2O) Blood 290 Low osmolality (non-ionic, monomeric) Xenetrix (Iobitridol) 350 724 Ultravist (Iopromide) 300, 370 605, 780 Omnipaque (Iohexol) 300, 350 685, 823 Iopamiro (Iopamidol) 300, 370 653, 832 Iomeron® (Iomeprol) 400 724 Contrast media: safety and comfortability
Class Iodine content Osmolality (mg/ml) (mOsm/KgH2O) Blood 290
Low osmolality (non-ionic, dimeric) Isovist (Iotrolan) 300 294 Visipaque (Iodixanol) 270, 320 290, 290 Product Chemical % salt I (mgI/ml) Viscosity Viscosity Osmolality structure concen 25°C(cps) 37°C(cps) mOsm/Kg
tration H2O Omnipaque® Iohexol None 350 20.4 10.4 844 350 75.5%
Optiray™ Ioversol None 350 14.3 9.0 792 350 74%
Ultravist® Iopromide <0.1 370 22.0 10.0 774 370
Iomeron® Iomeprol None 400 27.5 12.6 724 400 81.65%
Visipaque® Iodixanol None 320 26.6 11.8 290 320
Hexabrix™ Ioxaglate 39.3 320 15.7 7.5 600 Meglumine/ 19.6 sodium BJU International (2000), 86 Suppl. 1, 1-10 Contrast media
The “ Ideal” intravascular contrast media Water-soluble Heat/ chemical/ storage stability Non-antigenic, Low-antigenic Low viscosity Lower or same osmolality compared to plasma Safety Low cost Contrast media การออกแบบโครงสร้างของ Contrast Media Feature Significance Solubility Maximum possible concentration Viscosity Speed of injection, infusion. Osmotic pressure Pain in some angiographic indications, endothelial damage, hypervolemia Lipophilia Frequent general reaction hydrogen bonding (nausea, vomiting, allergy-like reactions) Electrical charge Improvement of solubility /Iopamiro /Omnipaque /Xenetrix
/Optiray /Ultravist
/Isovist /Visipaque Contrast media
Safety Contrast Media is relatively a toxic substance. How safe it is to administer to patient? ADRs (adverse drug reactions) PC-AKI (Post contrast acute kidney injury) CIN (contrast induce nephropathy) Contrast media
ผลของ Iodinated Contrast Media ต่อรา่ งกาย Mechanisms of Toxicity (กลไกในการเกิดพิษต่อรา่ งกาย) Hyperosmolality (ความเหมข้มข้นสูง) Acute expansion of plasma volume , generalized vasodilation, an effect on smooth muscle, rigidification of red cells, histamine release from basophils and mast cells and endothelial injury Chemotoxic effects(พิษจากสารเหมคมี) From properties of CM molecules, non specific interaction Charge (ประจุ) Contrast media
Safety Contrast Media is relatively a toxic substance. How safe it is to administer to patient? ADRs (adverse drug reactions) PC-AKI (Post contrast acute kidney injury) CIN (contrast induce nephropathy)
Contrast media Incidence of ADRs Katayama et al; Radiology 1990:175:621-28 Adverse reaction (ADRs) Ionic contrast in 169,284 patients = 12. 66% Low osmolality non ionic contrast 168,363 patients = 3.13% Severe ADRs for ionic group = 0.22% Severe ADRs for non ionic group = 0.04% Each group death = 1 patient Overall acute adverse reaction rate of 0.2% - 0.7% for nonionic LOCM administered (allergic-like + physiologic) Pediatrics overall acute adverse reaction rate of 0.18%- 0.46%. (allergic-like+ physiologic) Contrast media
First 5 common ADRs
Ionics(%) Nonionic(%) Nausea 4.58 1.04 Urticaria 3.16 0.47 Itching 2.97 0.45 Heat sensation 2.29 0.92 Vomiting 1.84 0.36 http://apjai-journal.org/wp-content/uploads/2016/10/7AdversereactionsAPJAIVol31No4December2013P299.pdf Contrast media Nearly all life-threatening reactions มักจะเหมกิดใน 20 นาทีแรก หลังการได้รับ Contrast Media “test injection” ไม่ลด incidence ของ severe reactions และ อาจจะเหมพิ่มด้วย ไม่เหมรียกปฏิกิริยาว่าเหมป็น Anaphylaxis แต่เหมรียก “Anaphylactoid” “non-allergic anaphylactic” เหมนื่องจากไม่พบantigen -antibody response การรักษาเหมช่นเหมดียวกับ allergic anaphylactic reaction พยาธิสภาพการเหมกิดปฏิกิริยายังไม่ทราบแน่ชัด Contrast media อัตราการเหมกิดและความรุนแรงพบว่าลดลงถ้าใช้ low- osmolality and isotonic contrast media. Predictor ที่ดีที่สุดสาหรับโอกาสที่จะเหมกิดอาการแพ้คือ เหมคยมีอาการแพ้ CM มา ก่อน โดยมีโอกาสเหมกิดซ ้า 8% ถึง 30% ถ้ามีประวัติ Active allergies มักเหมกิด Urticarial reactions ถ้ามีประวัติ Asthma มักเหมกิด Bronchospasm reactions. คนไข้ที่มีประวัติแพ้อาหารทะเหมลหรือแพ้ยาบางชนิดที่มี iodine เหมป็น ส่วนประกอบเหมช่น Betadine ไม่มีความเหมสี่ยงเหมพิ่มเหมมื่อเหมทียบกับคนไข้ที่มีประวัติ แพ้ทั่วๆไป Contrast media
Hemodynamic changes จะพบได้บ่อยในกลุ่มที่มีอาการของโรคหัวใจ และหลอดเหมลือด เหมช่น aortic stenosis หรือ severe congestive heart failure การเหมกิด Mild reactions อาจเหมป็นอาการน าของ severe reactions (จึง ควรดูอาการประมาณ 20-30 นาทีหลังให้ contrast media) Rare delayed reaction: Iodide “mumps” (iodine-related sialoadenopathy or salivary gland swelling) and acute polyarthropathy. ไม่มี cross reaction ของ Contrast ต่างชนิด เหมช่นMRI และ Iodinated contrast Contrast media
Safety Contrast Media is relatively a toxic substance. How safe it is to administer to patient? ADRs (adverse drug reactions) PC-AKI (Post contrast acute kidney injury) CIN (contrast induce nephropathy) Contrast media Post-contrast acute kidney injury (PC-AKI) is a general term used to describe a sudden deterioration in renal function that occurs within 48 hours following the intravascular administration of iodinated contrast medium. PC-AKI may occur regardless of whether the contrast medium was the cause of the deterioration PC-AKI is a correlative diagnosis. Contrast media
Contrast-induced nephropathy (CIN) is a specific term used to describe a sudden deterioration in renal function that is caused by the intravascular administration of iodinated contrast medium; therefore, CIN is a subgroup of PC-AKI. CIN is a causative diagnosis. The exact pathophysiology of CIN is not understood. Contrast media
Diagnosis AKIN Definition of Acute Kidney Injury The diagnosis of AKI is made according to the AKIN criteria if one of the following occurs within 48 hours after a nephrotoxic event (e.g., intravascular iodinated contrast medium exposure): 1) Absolute serum creatinine increase ≥0.3 mg/dL (>26.4 µmol/L). 2) A percentage increase in serum creatinine ≥50% (≥1.5-fold above baseline). 3) Urine output reduced to ≤0.5 mL/kg/hour for at least 6 hours. Contrast media Lab test for renal function screening before CM administration • ต้องตรวจ Serum BUN & serum Creatinine ก่อนให้ CM หรือไม่ • ควรดูจาก Risk assessment • เหมมื่อไหร่ต้องตรวจใหม่ ประมาณ 30 วัน eGFR Serum creatinine มีข้อจากัดในการใช้เหมป็นตัวชี้วัดการท างานของไตเหมนื่องจาก เหมปลี่ยนแปลงได้ง่ายตามเหมพศ อายุ มวลกล้ามเหมนื้อ (muscle mass) รวมถึง สภาวะ โภชนาการ Glomerular Filtration Rate เหมป็นค่าที่บอกการท างานของไตได้ดีกว่าแต่วัด โดยตรงยาก ปัจจุบันนิยมใช้ค่า estimated GFR (eGFR) เหมป็นตัวบ่งบอกการท างานของไต ค่า eGFR คานวณได้จากค่า Creatinine clearance/ serum creatinine Contrast media คนไข้แบบไหนบ้างที่ควรตรวจ BUN, Cr, eGFR ก่อนได้รับ CM Age > 60 History of renal disease, including: ◦ Dialysis ◦ Kidney transplant ◦ Single kidney ◦ Renal cancer ◦ Renal surgery History of hypertension requiring medical therapy History of diabetes mellitus Metformin or metformin-containing drug combinations* Contrast media
Metformin or metformin-containing drug combinations* Metformin does not confer an increased risk of CIN. However, patients who develop AKI while taking metformin may be susceptible to the development of lactic acidosis. Any factors that decrease metformin excretion or increase blood lactate levels are important risk factors for lactic acidosis. Contrast media Metformin or metformin-containing drug combinations* Category I In patients with no evidence of AKI and with eGFR ≥30 mL / min/1.73m2, there is no need to discontinue metformin either prior to or following the intravenous administration of iodinated contrast media, nor is there an obligatory need to reassess the patient’s renal function following the test or procedure. Contrast media Metformin or metformin-containing drug combinations* Category II In patients taking metformin who are known to have acute kidney injury or severe chronic kidney disease (stage IV or stage V; i.e., eGFR< 30), or are undergoing arterial catheter studies that might result in emboli (atheromatous or other) to the renal arteries, metformin should be temporarily discontinued at the time of or prior to the procedure, and withheld for 48 hours subsequent to the procedure and reinstituted only after renal function has been re- evaluated and found to be normal. Contrast media
ระดับ Cr เหมท่าใดไม่ให้ contrast จากแบบสอบถาม For patients with no risk factors other than elevated serum creatinine, (mean, 1.78 mg/dL) 35% used 1.5 mg/dL, 27% used 1.7 mg/dL, 31% used 2.0 mg/dL Patients with diabetes mellitus (mean: 1.68 mg/dL). Contrast media
ระดับ eGFR เหมท่าใดไม่ให้ contrast At the current time, there is very little evidence that IV iodinated contrast material is an independent risk factor for AKI in patients with eGFR ≥30 mL / min/1.73m2. Therefore, if a threshold for CIN risk is used at all, 30 mL / min/1.73m2 seems to be the one with the greatest level of evidence. ACR manual 2018 Contrast media
คนไข้ที่มีปัญหาเหมรื่อง AKI อยู่ ให้ Contrast ได้หรือไม่ ไม่มีหลักฐานว่าจะทาให้ไตแย่ลง แต่กลุ่มนี้จะ susceptible ต่อ nephrotoxin exposure จึง ควรระวังหรือหลีกเหมลี่ยง คนไข้ ESRD ให้ Contrast media ได้ Contrast media
Contrast induced nephropathy Is iso-osmolality better? Any medication help? Contrast media
Nephrotoxic Effects in High-Risk Patients Undergoing Angiography Whether iso-osmolality contrast medium is less nephrotoxic than low-osmolality contrast medium in high-risk patients? Conclusion: Nephropathy induced by contrast medium may be less likely to develop in high-risk patients when iodixanol is used rather than a low-osmolality, nonionic contrast medium. YES
Aspelin,P et al. N Engl J Med 2003;348:491-9 Contrast media
Renal failure in 57,925 patients undergoing coronary procedures using iso-osmolar or low-osmolar contrast media. Risk of developing renal failure and required dialysis after coronary procedures is higher when patients received iodixanol than ioxaglate or iohexol OPPOSITE
Liss P.et al. Institute of Radiology, Uppsala,Sweden Kidney Int. 2006 Nov;70(10):1811-7. Epub 2006 Sep 27. Contrast media
Nephrotoxicity of iso-osmolality and low-osmolality contrast agents was similar when a prophylactic strategy of hydration plus N-acetylcysteine (NAC) was utilized.
Briguori C et al ; Italy. Kidney Int. 2005 ; Nov;68(5):2250-5 Contrast media
Nephrotoxic effects of iodixanol and iopromide in patients with abnormal renal function receiving N-acetylcysteine and hydration before coronary angiography and intervention: a randomized trial. iodixanol was not associated with a statistically significant lower incidence of CIN when compared with iopromide. SAME
Juergens CP. et al ; NSW , Australia. Intern Med J. 2009 Jan;39(1):25-31. Contrast media Intra-arterial use The overall incidence of PC-AKI in studies of cardiac angiography is higher than it is in studies of patients who receive Intravenous iodinated contrast medium. Cardiac angiography differs from IV contrast medium administration in three major ways: 1) the injection is intra-arterial and supra-renal, 2) the injection requires a catheter that can dislodge atheroemboli, 3) the contrast medium dose to the kidneys will be more abrupt and concentrated . Contrast media Heat, discomfort, pain Warming help? Low osmolality help? Contrast media Warming of Iodinated Contrast Media – Suggestions Based on the available literature, the validity of extrinsic warmers seems predicated on the intended outcome. Extrinsic warming of iodinated contrast material to human body temperature (37°C) may be helpful to minimize complications and improve vascular opacification in the following circumstances: • For high-rate (> 5 mL/second) IV LOCM power injections • For injections of viscous iodinated contrast (e.g., iopamidol 370, and presumably other contrast media with a similar or higher viscosity) • For direct arterial injections through small-caliber catheters (5 French or smaller) • For intravenously injected arterial studies in which timing and peak enhancement are critical features (CTA) ACR 2018 Contrast media
Warming of Iodinated Contrast Media – Suggestions Extrinsic warming of iodinated contrast material may NOT be needed or beneficial in the following circumstances: • For low-rate (≤ 5 mL/second) IV LOCM power injections or hand injections • For injections of iodinated contrast media with a relatively low viscosity (e.g., iopamidol 300, and presumably other contrast media with a similar or lower viscosity) • For direct arterial injections through large-bore catheters (6 French or larger) • For IV injections in which peak opacification and timing are not critical (e.g., routine portal venous phase chest/abdomen/pelvis CT imaging) Contrast media
Comfortability Heat, discomfort, pain Warming help? Low osmolality help? Contrast media
Intravenous injections may cause heat and discomfort but rarely cause pain unless there is extravasation. Intra-arterial contrast injections into peripheral vessels in the arms, legs, or head can be quite painful particularly with HOCM. For such injections, iso-osmolality contrast media (IOCM) are associated with the least amount of discomfort.
Acta Radiologica 2014, Vol. 55(6) 715–724 Contrast media Comparison of patient comfort between iodixanol and iopamidol in contrast-enhanced computed tomography of the abdomen and pelvis: a randomized trial Sensation of heat or pain upon injection represents physiologic responses to contrast material, and increases in incidence and severity with increasing contrast osmolality and dose prospective, randomized, double-blind, multicenter study of iodixanol 320 mg I/mL or iopamidol 370 mg I/mL on patient discomfort. The presence of discomfort (heat, pain, coldness) and intensity was verbally rated by patients on a 0–10 scale and converted into four categories (0, none; 1–3, mild; 4–7, moderate; 8–10, severe). Image quality was evaluated. Of the 299 evaluable patients enrolled at nine centers, 151 received iodixanol and 148 received iopamidol. The average age was 58 years Acta Radiologica 2014, Vol. 55(6) 715–724 Contrast media
Patients receiving iodixanol had significantly lower moderate-to- severe or severe discomfort than patients receiving iopamidol, with heat being the major contributor. Iodixanol use trended towards better image quality but the difference was not statistically significant. No significant differences in incidences of overall or contrast- related AEs or delayed skin reactions were seen between the two groups. These data support that CM osmolality may be a key determinant of patient discomfort. Acta Radiologica 2014, Vol. 55(6) 715–724 Contrast media Other general issues Age, Gender Beta blockers Diseases – Sickle Cell, Pheochromocytoma, myasthenia gravis, Hyperthyroidism Thyroid radioactive iodine therapy, radioactive iodine imaging of the thyroid gland The washout period is ideally 3-4 weeks for patients with hyperthyroidism, and 6 weeks for patients with hypothyroidism Pretesting: Intradermal skin testing with contrast media to predict the likelihood of adverse reaction NOT useful. Contrast media Other general issues Corticosteroid premedication: Benefit, Direct risk and Indirect risk Premedication does not prevent all contrast reactions. Allergic- like contrast reactions that occur despite premedication are called “breakthrough reactions Patients premedicated for a prior contrast reaction have a breakthrough reaction rate = 2.1% Oral premedication is preferable to IV premedication Contrast media
Safe injection Power injector through a flexible plastic cannula Proper flow rate Central venous catheter: manufacturer recommendation Problems Air embolism Extravasation 0.1% to 1.2% Broken catheter tip Contrast media Safe injection The Power PICC line by BARD Access Systems
Cook Spectrum PICC Contrast media
Smart Port by AngioDynamics
Power Hickman catheter by BARD Contrast media Consent: intravenous injection of contrast media may be exempted from the need for informed consent, but this decision should be based on state law, institutional policy, and departmental policy Contrast media
Ultrasound X ray source modalities (General Radiology, Fluoroscopy, CT, Angiogram) (Intravenous, Intra- arterial, Intra-articular, Intra-osseous route) MRI Contrast media
All gadolinium-based contrast agents (GBCAs) share a common structure of an organic ligand that tightly binds to and improves the stability, solubility, and safety of the central gadolinium heavy metal ion. In typical patients, the chelate is mostly eliminated via the kidneys, with some amount of liver excretion demonstrated for a few of the agents. https://pubs.rsc.org/image/article/2008/DT/b719704g/b719704g-c1.gif Contrast media
Gadolinium contrast agents can be categorized into: Extracellular fluid agents Blood pool agents Hepatobiliary (liver) agents Contrast media Extracellular fluid agents gadoterate (Dotarem, Clariscan) gadodiamide (Omniscan) gadobenate (MultiHance) gadopentetate (Magnevist) gadoteridol (ProHance) gadoversetamide (OptiMARK) gadobutrol (Gadovist [EU] / Gadavist [US]) gadopentetic acid dimeglumine (Magnetol) Contrast media Blood pool agents Albumin-binding gadolinium complexes gadofosveset (Ablavar, formerly Vasovist) gadocoletic acid Polymeric gadolinium complexes gadomelitol gadomer 17 Hepatobiliary (liver) agents gadoxetic acid (Primovist [EU] / Eovist [US]) is used as a hepatobiliary agent as 50% is taken up and excreted by the liver and 50% by the kidneys. Contrast media
The adverse event rate for GBCM administered at clinical doses (0.1– 0.2 mmol/kg for most GBCM) ranges from 0.07% to 2.4%. Most reactions are mild and physiologic, including coldness, warmth, or pain at the injection site; nausea with or without vomiting; headache; paresthesias; and dizziness. Allergic- like reactions are uncommon and vary in frequency from 0.004% to –0.7%. The manifestations of an allergic- like reaction to a GBCM are similar to those of an allergic-like reaction to an iodinated contrast medium. Contrast media
Severe life threatening anaphylactic reactions occur but are exceedingly rare (0.001% to 0.01%) In a survey of 20 million administered doses, there were 55 severe reactions. A large single-institution study that included more than 100,000 GBCM injections demonstrated an allergic-like reaction frequency of 0.15%, with 0.13% mild reactions and 0.006% severe reactions (six reactions). Fatal reactions to gadolinium chelate agents occur but are extremely rare. Treatment of acute adverse reactions to GBCM is similar to that for acute reactions to iodinated contrast media . Contrast media
Nephrogenic systemic fibrosis (NSF) is a disease, primarily involving the skin and subcutaneous tissues but also known to involve other organs, such as the lungs, esophagus, heart, and skeletal muscles. Initial symptoms typically include skin thickening and/or pruritus. Symptoms and signs may develop and progress rapidly, with some affected patients developing contractures and joint immobility. In some patients, the disease may be fatal. It is now generally accepted that GBCA exposure is a necessary factor in the development of NSF, although in rare instances NSF can be diagnosed without known GBCA exposure. The time between injection of GBCA and the onset of NSF symptoms occurs within days to months in the vast majority of patients; even years in rare cases. Contrast media
Risk factors for NSF CKD (4and 5) High-dose and multiple exposures metabolic acidosis or medications that predispose patients to acidosis high-dose erythropoietin therapy Contrast media Contrast media
Recently, residual gadolinium has been found within the brain tissue of patients who received multiple doses of GBCAs over their lifetimes. For reasons that remain unclear, gadolinium deposition appears to occur preferentially in certain specific areas of the brain, even in the absence of clinically evident disease and in the setting of an intact blood brain barrier. To date, no adverse health effects have been uncovered Gadolinium deposition in the brain may be dose dependent and can occur in patients with no clinical evidence of kidney or liver disease. Contrast media
Extravasation of Gadolinium Based Contrast Media Gadolinium-based MRI contrast media have similar to lower toxicity in comparison to iodinated contrast agents: however, extravasations of these agents usually do not cause severe injury, likely due to the smaller total volumes of contrast material that are injected at MRI. Extravasation events to GBCM are rare, with one series demonstrating a rate of 0.05% Contrast media
Other issues: Warming of Gadolinium-Based Contrast Media—Suggestions Gadolinium-based contrast media are administered at room temperature (15 to 30o C ) and according to package inserts, should not be externally warmed for routine clinical applications. CIN Gadolinium-based contrast media either do not cause CIN when administered at FDA-approved doses, or this event is exceptionally rare. If administered at extreme above-FDA-label doses to achieve X-ray attenuating effects during angiography (not recommended), gadolinium-based contrast media are more nephrotoxic than iso-attenuating doses of iodinated contrast media Contrast media
Other issues: Metformin and Gadolinium It is not necessary to discontinue metformin prior to contrast medium administration when the amount of gadolinium-based contrast material administered is in the usual dose range of 0.1 to 0.3 mmol per kg of body weight. Calcium Level Some linear nonionic GBCM (e.g., gadoversetamide, gadodiamide) may interfere with total serum calcium values as determined with some calcium assay methods Contrast media
Conclusion • มี contrast ให้เหมลือกใช้มากมาย • ความรู้เหมกี่ยวกับ contrast มีความจาเหมป็นอย่างยิ่งเหมพื่ อให้เหมลือกใช้ ได้อย่างถูกต้อง ปลอดภัยและคุ้มค่า • ปัจจัยสาคัญในเหมรื่องความปลอดภัยทางด้าน รังสีวิทยาคือการ เหมลือกและการเหมตรียมผู้ป่วยอย่างถูกต้อง • มีความจาเหมป็นที่ต้องมีการท าวิจัยมากขึ้นในประเหมทศไทย เหมนื่องจากเหมครื่องมือใหม่ๆ และ contrast ใหม่ๆมีออกมา ตลอดเหมวลา Contrast media
Conclusion การบรรยายนี้ไม่ร่วมเหมนื้อหาเหมกี่ยวกับ Contrast media in children Contrast media in pregnant and breast feeding women GI contrast References https://www.acr.org/Clinical-Resources/Contrast-Manual Canadian Association of Radiologists Journal 68 (2017) 187e193 Adverse Reactions to Contrast Material: A Canadian Update https://www.ranzcr.com/college/document-library/ranzcr-iodinated-contrast- guidelines http://radprompt.com/th/2018/05/14/lecture-contrast-media-update-on- guidelines-and-hot-issues/ https://ctisus.com/learning/features/contrast/contrast-iv-contrast-q3 https://pubs.rsna.org/doi/pdf/10.1148/rg.2015150033 https://www.radiologyinfo.org/en/info.cfm?pg=safety-contrast