Contrast Material and in

Leeanne Langston, BS, RRA, RPA, RT(R) The government agency responsible for ensuring that marketed in the US are safe and effective Food and Administration (FDA) The government agency responsible for enforce the controlled substances laws and regulations Drug Enforcement Agency (DEA) What’s in a name?

Generic or Brand?

Brand name: refers to the trade name developed by the company (Tylenol)

Generic name: is the official name of a drug (Acetaminophen) Generic drugs are copies of brand- name drugs, they must have the exact same pharmacological effects as their counterparts Common Ways of Administering Contrast or Meds

oral: by mouth sublingual: under the tongue enteric: delivered directly into the stomach nasal: sprays or pumps parenteral: injection or infusion (IM, IV, SC) rectal: suppository inserted into the rectum Intramuscular: inject at 90 degrees Intravenous injection: most common site is median cubital vein Cutaneous injection: “sub-cu” absorption is slow Intrathecal injection: administering contents w/ CSF

Local

Generic Name Trade Name Onset Duration of Action (min) Procaine Novocain moderate 30-60 hydrochloride

Lidocaine Xylocaine rapid 80-120 hydrochloride

Bupivacaine Marcaine Longest 180-360 hydrochloride (2–10 min)

Ropivacaine Naropin moderate 140-200 hydrochloride Lidocaine (Xylocaine) Bupivacaine (Marcaine)

Quicker onset Slower onset

Short duration Longer duration

Max safe dose 300mg Max safe dose 150mg (500mg w/ epinephrine) (225mg w/epinephrine)

CNS toxicity w/ excessive cardio toxic doses

Can be mixed w/ sodium Can be mixed w/ bicarbonate to stinging for longer (short term) relief Contraindications and Risks

Both have very low risk of allergic reaction Previous allergy to Novocain is NOT contraindication to use Lidocaine Moderate/Conscious Sedation

ASA defines moderate sedation as: a minimally depressed level of consciousness induced by the administration of pharmacological agents in which the patient retains a continuous and independent ability to maintain protective reflexes, a patent airway, and the ability to be aroused by physical or verbal stimulation. Physical status classifications used by the ACR-SIR based on the ASA guidelines

ASA Guidelines ACR-SIR Guildelines

Class 1: normal healthy Class 1 & 2: low risk, no patient further recommendations

Class 2 & 3: mild/moderate Class 3 & 4: may require systemic disease further consideration

Class 4: severe systemic disease

Class 5: not likely to survive Class 5: do not proceed w/o w/o procedure anesthesia Preprocedural Evaluation

. Medical history . Previous adverse experience w/ sedation . Allergies . Current meds . NPO . Labs . Patient consent The Commission

Requires history & physical documentation risks and options be discussed

Does NOT require a separate consent in addition to hospital consent

Pre-post procedural documentation w/ 48 hrs Equipment used during moderate sedation

• Intravenous access • Cardiac monitor • Automatic pressure cuff • Pulse oximeter • Oxygen source • Suction equipment • Code Cart should always be available ACR-SIR Procedure Monitoring Guidelines

. Intravenous access . Homeothermia should be preserved . Protected from pressure or position related injuries . Physiologic measurements every 5 mins level of consciousness respiratory rate pulse BP heart rate cardiac rhythm Procedure Documentation

Documentation, documentation, documentation given, dose, route, time, response Depth of sedation: Ramsey Scale 0) none, patient is awake 1) Mild, occasionally drowsy 2) Moderate, frequently drowsy, easy to arouse 3) Severe, difficult to arouse “S” Sleeping Post-Sedation Care

 Returned to baseline level of consciousness  Vital signs are stable  Sufficient time since reversal agent given  OP discharged to a (responsible) adult  Provided w/ written instructions (ASA does not dictate a specific scoring system but best known is Aldrete scoring) Medications

Lorazepam Indications

Contraindications

Dosing Guidelines

Naloxone Diazepam Contraindications/High Risk . Allergies to medication . Chronic Renal Failure . Currant medications . Chronic Liver Failure . Morbid Obesity . Elderly/Peds . COPD . Pregnancy . CAD Opioids Benzodiazepines

Used for pain control Used for Morphine (morphine sulfate) Diazepam (valium) Fentanyl (fentanyl citrate) Midazolam (versed) Meperidine (Demerol) Lorazepam (Ativan) Opioids

• Most effective for relieving dull, tonic pain • Less effective for intermittent sharp pain • Causes mild sedation • Causes respiratory depression • Can nausea, vomiting • Does cross the placenta • Does NOT cause amnesia Benzodiazepines

. Sedation and hypnosis . Minimal respiratory depression . Decreased anxiety . Pronounced effect on . Increased muscle elderly/peds relaxation . Can cross the placenta . Antegrade amnesia and are excreted in . properties breast milk Opioids commonly used in moderate sedation

Brand Name onset duration dose

Morphine Less than Up to 4 hrs 2mg 10 mins Fentanyl 2 -3 mins 30 – 60 mins 25ug Causes less hypotension/ Cardiovascular depression Demerol 5 – 15 mins 2 – 4 hrs 10 -25mg Not used w/ hx cardiac disease Benzodiazepines commonly used in moderate sedation

Brand Name onset duration dose

Versed 1 – 3 mins 1 hr 1mg

Valium 2 – 3 mins Up to 6 hrs 1 – 2mg

Ativan 30 – 60 mins Can be long 2mg lasting Opioid overdose

Characterized by: decreased respiratory drive hypotension significant nausea/vomiting

Reversal agent

Narcan Narcan (Naloxone)

Can be inject:

IV 0.1mg – 0.3mg effective w/ 2 mins

IM 0.4mg effective w/ 5 mins

Nasal spray 4mg

Short duration of action (20-30 mins) may have to be repeated Benzodiazepine overdose

Characterized by: deep sedation deep respiratory depression decreased response to external stimuli

Reversal agent

Romazicon Romazicon (Flumazenil)

Injected IV series of small amounts 200 ug per 1 min up to 1mg

Short acting 30 – 60 mins resedation can occur if reinjection is necessary airway support should be considered bacterials fungals

Are anti-infective drugs that kill or stop the spread of an infectious agent Hypertension

1 out of 3 adults in America has high blood pressure Antihypertensive Meds

Calcium channel ACE inhibitor Beta blockers blockers

Most widely used Recommended for Promote lower heart considered “first line” pt under 55 or pt rate & reduce tremors treatment w/ ESRD

Ultimate goal is to lower blood pressure to prevent heart attack, stroke, heart failure Vasopressors: cause blood vessels to constrict which will

the flow of blood blood pressure

Epinephrine ACLS Vasopressin Vasodilators: cause widening of walls of blood vessels

blood flow blood pressure

Nitroglycerin (angina, acute coronary artery syndrome) Modifiers

Act on blood coagulation pathway to either promote or prevent blood clot formation

Anticoagulants: prevents venous and arterial clot formation

Antiplatelet Agents: prevent arterial clot formation

Thrombolytics: dissolves blood clots

Hemostatics: promotes clot stability Fibrinolytic Drugs

Are used to break down/dissolve blood clots

Three most commonly used are:

tPA tissue plasminogen activator SK streptokinase UK urokinase Indications

Myocardial infarction Pulmonary embolus Acute ischemic stroke Deep vein thrombosis Ischemic limb injury Contraindications/side effects

Suspected hemorrhagic stroke Recent trauma Previous GI bleed Pregnancy Recent surgery Advance liver disease Gastrointestinal drugs : used to treat nausea/vomiting GERD: proton pump inhibitors GIST: Gleevec IBS: helps w/ diarrhea constipation IBD: Crohn: Cimzia UC: Asacol Anti-Inflammatory Drugs (OTC)

Nonsteroidal anti-inflammatory drugs Steroids (NSAIDs) ()

Analgesics, antipyretic Reduce inflammation Anti-inflammatory suppress the Aspirin, Ibuprofen Naproxen Orally, injected, Inhalers, topical Non-narcotic/non-addictive Acetaminophen NSAIDs (Tylenol) (Aspirin)

Analgesic Antipyretic Antipyretic Does NOT reduce Anti-inflammatory inflammation generally slightly more generally a little safer effective should only be used for short period of time Adverse effects/risks

NSAIDs: GI upset (n/v/d/c) severe cases ulcer/bleed Acetaminophens: liver damage Corticosteroids: a lot depends on how you are using them Responding to adverse/allergic reaction to contrast

BEST Response

Be cautious and pre medicate Two frequently used regiments recommended by ACR

1) Prednisone – 50 mg po @ 13 hrs, 7 hrs and 1 hr before contrast inj, plus 50 mg Benadryl (IV, IM, PO) 1 hr prior 2) Medrol – 32 mg PO 12 hrs and 2 hrs prior to inj plus 50 mg Benadryl 1 hr prior Greatest effect on pt’s w/ previous mild/moderate contrast reactions High risk patients

Any pt that has experienced an anaphylactic reaction in response to an allergy to anything

Prior contrast allergy Renal insufficiency Cardiac disease Asthma When assessing a patient for possible contrast reaction

. How does the patient look? . Can the patient speak? How does pt’s voice sound? . How is the pt’s breathing? . What is the pt’s pulse strength and rate? . What is the pt’s blood pressure? Moderate reactions requiring medical intervention

Allergic-like Physiologic

. Diffuse hives/itchy skin . Protracted . Diffuse erythema nausea/vomiting . Facial edema w/o . Hypertensive urgency dyspnea . Isolated chest pain . Throat . Vasovagal reaction tightness/hoarseness requires treatment w/o dyspnea . Wheezing/bronchospasm Severe reaction:

When any of the “moderate” reactions goes down hill quickly

“CALL A CODE” The worst response to “how are you feeling”

“I’m feeling a little funny/strange”

W/o any possible prediction or prior history of any reactions to meds or contrast these (few) pt’s fit into a category called

Idiosyncratic drug reactions What is contrast media?

It is a substance that is either radiolucent or radiopaque that is administered to increase

radiographic contrast in an organ Contrast enhanced exams

Why do we use contrast?

Contrast increases the native (existing contrast) of organs

It separates them from surrounding tissue

It provides information on size, shape and position of structures

It can increase or decrease the density of a structure What are the desirable features of a

. Easy to administer . No toxicty/carcinogenicity . Stable compound . Concentrates in area of interest . Proper demonstration of the organ system . Should have rapid elimination . Minimal distress to patients . Cost effective All contrast media are not the same

Viscosity Osmolality Chemotoxicity LD50 (Lethal Dose given all at once which causes the death of 50% of a test group of animals) Two basic categories

Negative Positive

double contrast Negative contrast agents are gases of low density which appear radiolucent

air oxygen

Carbon dioxide CO2 Positive contrast has high atomic numbers and appears radiopaque on images

Water soluble Water insoluble

Iodinated contrast sulfate

ionic Non ionic

HOCM LOCM Iso osmolar Ionic Non ionic HOCM LOCM

• High osmolality • Low osmolality • Associated w/ higher • Fewer side effects, incidence of adverse most are mild reaction • Approximately twice • Weaker ability to the osmolality of attenuate x-rays, human serum leading to higher • Usually more concentrations expensive

. Has better coating properties than . Can be ingested or rectally administered . Rare to have adverse reaction . NOT water soluble . NOT used for p/o pt’s . NOT used if question of GI perforation ( can be toxic if leaked into mediastinum or peritoneum) . Is inexpensive compared to Non ionic contrast Mri contrast agents

Gadolinium based compounds are the most commonly used

Currently there are 9 contrast agents approved in USA by FDA

Very well tolerated w/ very low incidence of adverse reaction Risk factors w/ GBCM

Pt w/ previous allergic-like reaction

Pt w/ acute or chronic renal insufficiency GFR < 30

Pt w/ asthma Contraindications for MRI

Pacemaker, defibrillator Metallic FB in the eye Deep brain stimulator Swan-Ganz catheter Cerebral aneurysm clips Cochlear implant Magnetic dental implants Drug infusion devices Bullet or gunshot pellets Basic Life Support

“Annie Annie are Assess the pt you OK” Call for help

C A B

Compressions Airway Breathing 2 rescue 30 compressions tilt chin breaths ACLS

Vent, Asystole/ Bradycardia Tachycardia Fib/Tach PEA

Epinephrine Epinephrine Atropine Adenosine vasopressin Vasopressin Epinephrine Beta-blockers

Amiodarone Dopamine Amiodarone

Lidocaine ACLS cont.

Acute Coronary Syndrome Acute stroke

Oxygen tPA

Aspirin

Nitroglycerin

Morphine

Fibrinolytic therapy

Heparin References:

American Journal of Roentgenology (AJR) American College of Radiology (ACR) American Society of Anesthesiologist (ASA) RadioGraphics RSNA