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Contrast Media Chamaree Chuapetcharasopon, MD,MBA [email protected] 26 October 2019 8 November 1895 DISCLOSURE NONE 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
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