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Reducing Contrast Extravasation
Linda McDonald, MSN, RN, CRN
Radiology Advanced Practice Nurse
Children’s Hospital of Pittsburgh of UPMC
Dallas, TX • November 2–4, 2012
Objectives
• Discuss how contrast delivery is
different from most other medications
and how this impacts extravasation
• List three actions to reduce
extravasation potential during contrast
delivery
Dallas, TX • November 2–4, 2012
Extravasation of 70ml of
Iodinated Contrast Media
Dallas, TX • November 2–4, 2012
This took 17.5 seconds to happen
Dallas, TX • November 2–4, 2012
What is an extravasation ?
• “the inadvertent infiltration of vesicant
solution or medication into surrounding
tissue”
• Vesicant – “an agent capable of causing
blistering, tissue sloughing, or necrosis
when it escapes from the intended
vascular pathway into surrounding
tissues”
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Dallas, TX • November 2–4, 2012
What Does The Patient
Feel?
• Most feel a sensation of swelling or
tightness, Wang,et al reported 79%
experienced this
• Most also feel stinging or burning pain
at the site, Wang, et al reported 24%
experienced this
• Some feel nothing at all ,Wang, et al
reported 8% experienced no symptoms
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Dallas, TX • November 2–4, 2012
Incidence of Contrast
Extravasation
• American College of Radiology (ACR)
reports a 0.1% to 0.9% rate of
extravasation from power injection of
contrast media for a CT scan
• Equates to 1/1000 to 1/106 patients
• Frequency not related to injection flow
rate
Dallas, TX • November 2–4, 2012
What is IV contrast ?
• diagnostic material that alters x-ray
absorption by body tissues or organs
• can discriminate between disease and
normal tissue
• Many diseases would go undetected if
contrast media was not used
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Dallas, TX • November 2–4, 2012
Where is it used ?
• Computed Tomography (CT)
• Magnetic Resonance Imaging (MRI)
• Positron Emitting Imaging with CT
(PET/CT)
• Fluoroscopy
• Angiography
Dallas, TX • November 2–4, 2012
Types of IV Contrast
• Iodine-based contrast – used in CT,
Angiography, Fluoroscopy
- Ionic – 1st generation
- Non-ionic – 2nd generation
- Iso-osmolar – 3rd generation
• Gadolinium-based contrast – used in
MRI
Dallas, TX • November 2–4, 2012
Contrast Characteristics
That Are Problematic
• Osmolality
• Viscosity
• pH
Dallas, TX • November 2–4, 2012
Osmolality of Contrast
Media
• Osmolality – “number of milliosmoles
per kilogram of solvent”, measure of the
total number of particles (solutes) in a
solution
• Normal serum osmolality is 280-295
mOsm/kg H2O
• IV Contrast medias range from
290 - 1970 mOsm/kg H2O
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Dallas, TX • November 2–4, 2012
Viscosity of Contrast Media
• describes a fluid's internal resistance to
flow - a measure of fluid friction
water is “thin” with low viscosity
honey is “thick” with high viscosity
• Range from 2 - 26.6 cP
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Dallas, TX • November 2–4, 2012
pH of Contrast Media
• The acidity or alkalinity of a substance
• Blood has a pH of 7.35-7.45
• Range from 5.5 – 8.0
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Dallas, TX • November 2–4, 2012
Comparison of Iodinated IV
Contrasts
• Ionic – HOCM (high osmolar contrast media)
- osmolality 1000-1551 mOsm/kgH2O
- viscosity 6-16.4 cps at 25°C, 4-10.5 cps at 37°C
• Non-ionic – LOCM (low osmolar contrast media)
- osmolality 744-874 mOsm/kgH O
- viscosity 14.3-22 cps at 25°C, 9-10.4 cps at 37°C
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• Iso-osmolar – IOCM
- osmolality 290-769 mOsm/kgH2O
- viscosity 20.9-26.6 cps at 25°C, 9.4-26.6 cps at 37°C
Dallas, TX • November 2–4, 2012
Comparison of Gadolinium
Contrast Media
• Gadolinium
- osmolality 688 - 1970 mOsm/kgH2O
- viscosity 2 - 9.2 cps at 25°C
1.4 - 5.3cps at 37°C
Dallas, TX • November 2–4, 2012
How is IV Contrast Injected ?
• Hand injected by a syringe
• Mechanically injected by a power
injector
Dallas, TX • November 2–4, 2012
Why Use Power Injectors ?
• Best enhancement seen in 15 – 120
seconds after injection
• Small volumes can be quickly injected
by hand
• Larger volumes can not be injected fast
enough by hand
• Today there are CT scanners that can
scan a whole body in 5 seconds
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Dallas, TX • November 2–4, 2012
How Fast Does it Inject ?
• Rates ranging from 1-10ml per second
• Adult for CT of abdomen and pelvis with
contrast commonly receives 60ml of
contrast at 4ml per second
• 60ml is injected in 15 seconds
Dallas, TX • November 2–4, 2012
How Much Pressure is
Used ?
• Most injectors are set at a default of a
maximum pressure setting of 300-325
psi
• Injectors only exert the psi necessary to
deliver the contrast at the rate
programmed
Dallas, TX • November 2–4, 2012
What Steps Are Taken To
Prevent Extravasation ?
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Inspect the site
Verify blood return
Verify ability to flush easily with NSS
Verify patient has no discomfort with
NSS flush
• Verify that the catheter and accessory
products are power injectable
• Verify flow rate is appropriate for the
catheter size
Dallas, TX • November 2–4, 2012
What Steps Are Taken to
Detect Extravasation ?
• Patient instructions – get cooperation to
immediately tell RT if any pain or
sensation of swelling
• Palpation of site during first 15 seconds
of injection, then RT exits scan room
• Maintain communication with the patient
via intercom and/or video monitor
Dallas, TX • November 2–4, 2012
Equipment That May Help
Reduce Extravasation
• Extravasation detectors – sensors
placed on skin - designed to prevent
moderate to severe contrast
extravasations
• Dual head injectors that inject saline
prior to the contrast
Dallas, TX • November 2–4, 2012
ACR Recommendations
• ACR recommends use of the
antecubital or forearm vein – if smaller
hand or wrist vein is used then injection
rate should be decreased to 1.5ml/sec
• Metal needles should be avoided and
flexible plastic cannula used
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Dallas, TX • November 2–4, 2012
What IV Access Device is
Used?
• Central Venous Access Devices
– Power injectable catheters and ports
– Preferable because they are located in larger
central veins and power injection requires less psi
to deliver the desired rate
• Peripheral Venous Catheters
– Catheters must be power injectable
– Gauge of catheter must be large enough to
accommodate the required rate of flow
– Accessory devices must be power injectable
Dallas, TX • November 2–4, 2012
Short Peripheral IV Devices
• Infusion Nursing Standards of Practice
have stated these catheters are not
appropriate for “infusates with
osmolality >600mOsm/L.”
• Risk – Benefit assessment of the patient
to determine appropriateness of central
venous access vs. short peripheral IV
catheter access
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Dallas, TX • November 2–4, 2012
What Patients Are Most At
Risk of Extravasation
• Those unable to communicate
• Abnormal circulation in the limb to be
injected
• Altered circulation such as in PVD,
diabetic vascular disease, Reynaud’s
Disease
• Venous thrombosis or insufficiency
Dallas, TX • November 2–4, 2012
What Patients Are Most At
Risk of Extravasation cont.
• Multiple punctures in to the same vein
• Prior radiation or extensive surgery in
the limb to be injected
• Peripheral IV catheters that have been
in place more than 24 hours
• Catheters in sites such as the hand,
wrist, foot or ankle are at higher risk
Dallas, TX • November 2–4, 2012
When Extravasation Does
Occur What Happens ?
• Toxic to the surrounding tissues
especially the skin
• Acute local inflammatory response that
make peak in 24-48 hours
• Most will resolve without further
problems
• Rare occurrence of severe symptoms –
most common is Compartment
Syndrome
Dallas, TX • November 2–4, 2012
How Do We Reduce The
Incidence of Contrast
Extravasations?
• Collaboration of all disciplines
involved in the patient’s vascular
access
– ED and inpatient physicians & nurses
– IV Team
– Radiology
– Oncology
– Pharmacy
Dallas, TX • November 2–4, 2012
Case Study
• Contrast extravasation rate was 0.6%
• Volume of contrast extravasated was
commonly over 50ml
• 75% of contrast extravasations occurred
in pre-existing IV on ED or inpatients
• Non-power injectable accessory devices
were in use
Dallas, TX • November 2–4, 2012
Actions
• Education on contrast media, vein
selection, assessment of venous
access, assessment for use of power
injectable devices, & treatment of
extravasations for radiology RNs and
RTs
• Education expanded to include
radiologists and radiology residents
• Each extravasation was investigated
& patient was followed until resolved
Dallas, TX • November 2–4, 2012
Results
• Slightly improved outcomes
– Extravasation rate slightly decreased
– Volume of contrast extravasated was lower
– Use of only power injectable accessory
devices became the standard
– Still saw inpatients and ED patients
experiencing most of the extravasations
Dallas, TX • November 2–4, 2012
What Next ?
• Hospital Extravasation Task Force was
created – was a subcommittee of the
Patient Safety Committee
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Radiology
IV Team
Oncology
Patient Safety
Emergency Department
Inpatient Nursing
Plastic Surgery
Pharmacy
Dallas, TX • November 2–4, 2012
What Was Found ?
• Discovered that many pre-hospital IV
catheters were involved in extravasation
• Found that education for nurses,
paramedics and technologists varied
greatly
• Staff had no involvement with IV
product selection
• Extravasation treatment was
inconsistent
Dallas, TX • November 2–4, 2012
Next Steps
• Standardized mandatory IV education
housewide for all RNs and all IV
starters/injectors
• Changed hospital policy requiring IV
catheter removal within 24 hours for
those started outside the hospital
• Developed hospital extravasation policy
that defined vesicants and treatment,
standardized documentation of extravs
Dallas, TX • November 2–4, 2012
Collaborations
• ED and Radiology worked together
– ED RN or Paramedic would immediately
start a new IV with power injectable
accessories on all trauma and stroke
patients, this IV was indicated for use to
inject IV contrast
– Trauma Team changed brand of triple
lumen catheter to a power injectable one
Dallas, TX • November 2–4, 2012
Collaborations
• IV Team and Radiology worked
together
– Education done for IV Team RNs about
contrast media and need for certain gauge
catheters for certain studies
– PICC nurses included possible need for CT
and MRI contrast injection in their decision
algorithm for catheter selection which
resulted in more power injectable PICCs
inserted
Dallas, TX • November 2–4, 2012
Collaborations
• Oncology and Radiology worked
together
– Power Ports were only to be accessed with
a power injectable huber needle
– Education for the oncology staff regarding
contrast media injection focusing on
assessment of solutions that have been
administered through that catheter &
possible need of new site prior to CT
– Hospital port now power injectable
Dallas, TX • November 2–4, 2012
Results
FISCAL YEAR EXTRAVASATION RATES
0.70%
0.60%
0.60%
0.52%
0.50%
0.40%
0.30%
0.39%
0.34%
0.30%
0.20%
0.10%
0.00%
FY 2007
FY 2008
FY2009
FY 2010
FY 2011
FISCAL YEAR EXTRAVASATION RATES
Dallas, TX • November 2–4, 2012
Lessons Learned
• Collaboration is the key to successfully
reducing contrast extravasations
• Communication between all disciplines
involved in the patient’s care is
imperative
• We can improve patient safety and
satisfaction when we work together
Dallas, TX • November 2–4, 2012
References
1.
2.
3.
4.
5.
Infusion Nurse Society. (2011, January/February). Infusion Nursing Standards
of Practice. Journal of Infusion Nursing, ppS5-108.
American College of Radiology (2012). Retrieved August 30, 2012 from ACR
Manual on Contrast Media Version 8.
http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/Co
ntrast%20Manual/FullManual.pdf.
Gross, K., & Costa, N. (2008). Core Curriculum for Radiologic and Imaging
Nursing, 2nd Edition (pp1-83). Pensacola: American Radiological Nurses
Association.
MEDRAD XDS® Extravasation Detector. (2012), Bayer HealthCare Radiology
& Interventional. Retrieved August 30, 2012 from http://www.medrad.com/enus/info/products/Pages/XDS-details.aspx.
Wang, C., Cohan, R., Ellis, J., Adusumilli, S., & Dunnick, N.(2007, April).
Frequency, Management, and Outcome of Extravasation of Nonionic Iodinated
Contrast Medium in 69,657 Intravenous Injections. Radiology, pp 80-87.
Dallas, TX • November 2–4, 2012
Questions ?
[email protected]
Thank you
Dallas, TX • November 2–4, 2012