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JBI Database of Systematic Reviews & Implementation Reports
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The effectiveness of interventions to prevent or reduce Contrast
Media Extravasations among patients undergoing computerized
tomography scanning: a systematic review protocol
Sandrine Ding, PhD
1,2
Nicole Richli Meystre
1,2
Cosmin Campeanu, BSc, TRM
Gullo Giuseppe
1
3
1. University of Applied Sciences Western Switzerland, Haute École de Santé Vaud (HESAV),
Department of Technical Medical Radiology, Lausanne, Switzerland
2. Bureau d’Echange des Savoirs pour des praTiques exemplaires de soins (BEST) : an Affiliate
Center of the Joanna Briggs Institute, Lausanne, Switzerland
3. University Hospital of Lausanne (CHUV), Lausanne, Switzerland
Corresponding author:
Sandrine Ding
[email protected]
Review question/objective
The primary objective of the review is to identify the effectiveness of interventions to prevent or reduce
contrast medium extravasation in patients undergoing Computerized Tomographic examination. The
specific review question is: What is the effectiveness of methods to prevent or reduce Contrast Media
Extravasations among patients undergoing computerized tomography scanning?
Background
Computed tomography (CT) is a frequently conducted radiological examination and the number of CT
examinations continues to increase globally. For instance, in the United States, the number of CT
1
scans has more than doubled in 10 years, reaching 275 examinations per 1000 people in 2011. This
trend is likely to continue in the coming years due to the ageing of the population and the resulting
2
increase in chronic diseases, such as cardiovascular diseases, cancer and metabolic pathologies. CT
scanning has become indispensable for the diagnosis and follow up of a large variety of diseases
3
because of higher sensitivity and specificity compared to classical X-ray exams. This is the inevitable
result of its capacity to produce images of axial slices from which it is possible to make volumetric
3
reconstructions in three dimensions, or even in four dimensions with the creation of multiple cardiac
phase cine loops.
4
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Radiological examination by CT scan produces an image quality that is continually improving and
5
allows the visualization of hard tissue, such as bone, as well as parenchyma, such as liver. In order to
enhance the differentiation of the anatomy and abnormal structures, particularly for the vascular
6
system and viscera, iodinated contrast medium is routinely injected intravenously to the patient.
5
These contrast media allow differentiating between venous and arterial tissue phases. Evidence
7
indicates about 50% of CT exams use contrast medium, making it a widespread practice. Contrast
media are traditionally administered intravenously through manual or drip injection methods. However
these methods have been found to be variable in terms of injection flow rates and may negatively
8
affect specific organ enhancement. Increasing numbers of radiology departments are equipped with
automated power injectors for administration of contrast materials through peripheral venous catheters
9
at constant flow rate allowing specific angiographic and visceral enhancement.
The injection of radiographic contrast agents facilitates increased diagnostic or prognostic accuracy,
5
with clearer tissue differentiation or intravascular imaging by vessel opacification. Nevertheless,
contrast media have side effects, such as allergic-like reactions, vasovagal reaction, cardiac
arrhythmias or pulmonary edema.
8,10
Furthermore, a well-recognized important potential complication
11
is subcutaneous extravasation , which is defined as an accidental leakage of the injected fluid in the
surrounding tissue.
12
Extravasation constitutes an increased risk due to expanded use of power
injectors compared to manual or drip injection.
13,14
Because contrast media agents are vesicant, they
may cause injuries to the patients. In the best cases, the adverse effects may be mild with no severe
14,15
sequelae, e.g. inflammatory reactions,
but they nonetheless cause pain and discomfort to the
patient that may persist in the long term. However major adverse consequences such as skin
16
ulceration, soft-tissues necrosis or compartment syndrome have been documented.
are a risk, whether ionic or non-ionic contrast medium is injected.
Serious effects
16
When extravasation occurs, close patient monitoring is required to evaluate symptoms because the
reaction manifests itself several hours after injection and the timing and duration of subsequent
8
sequelae may vary substantially. The treatment of serious extravasation may require a surgical
fasciotomy, skin grafting or even amputation.
8,14,17,18
Furthermore, if complications associated with extravasation occur, the exam may be delayed and, a
new intravenous access has to be placed – inducing additional stress to the patients on top of the
known stressors associated with a CT scan.
19-21
Sometimes the CT examination must also be
repeated, which exposes the patient to an additional radiation dose and contravenes the “As Low As
22
Reasonably Achievable” (ALARA) principle of radiation protection.
The realization of a new injection
19
increases the cost due to the material used , the radiology personnel required and scanner utilization.
Furthermore it reduces radiological department workflow.
19
Accordingly, the financial and social
implications of such undesirable events are not negligible.
There are several strategies to prevent the extravasation that are related to the (i) healthcare
professionals, and (ii) technical tools used. Concerning healthcare professionals, IV administration
may be performed by persons from different professions: they may be nurses, radiographers or
23
radiologists. Researchers have investigated whether this factor might affect extravasation.
Additionally, training of the healthcare professional might be an important variable, and notably to
ameliorate the patient risk factors.
9,24
Indeed, it has been identified that certain patient characteristics
may induce an increased risk of extravasation. This is the case for patients with diabetes mellitus,
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venous thromboembolism, or cancer, or patients with altered communication (young children, elderly,
10,8,13,14,25
debilitated or unconscious patients).
Secondly, in relation to technical prevention methods, several have been reported in the literature.
These include strategies related to the characteristics of contrast media (including volume,
concentration, viscosity, temperature, and rate of administration)
6,8,13,23,26-28
as these have been shown
to increase or reduce extravasation (rate and volume). Similarly, the injection technique per se (patient
injection site, preparation room)
cannulas, butterfly, venflon)
13,14,25,26,28
6,13,23,25,26,28
and the material used for injection (catheter gauge,
may affect extravasation. Finally reduction of extravasation
rates could potentially be improved through the use of newly developed extravasation detection
29
apparatus (detection device: ultrasound, radiofrequency).
Knowing the effectiveness of these strategies is especially important for radiology personnel because
they can use, in their clinical practice, the most appropriate to prevent extravasation. This should also
help to improve the patient experience when undergoing a scanner examination. Primary research
articles have been published on the subject and their number has increased in recent years. In
addition, guidelines have been published by learned societies, but they are not based on systematic
literature reviews. Following a search in the JBI Database of Systematic Reviews and Implementation
Reports, Cochrane Library, Medline and Trip database, the authors found no systematic review
evaluating the scientific evidence of these strategies. It appears that it is worthwhile to conduct a
systematic review on the subject of the prevention and reduction of contrast media extravasation
during CT exam.
Keywords
Extravasation;contrast media; computed tomography; prevention; healthcare professionals; radiology;
frequency; volume; complications
Inclusion criteria
Types of participants
This review will consider studies that included patients (adults or children), undergoing a CT
examination, for any indication and of any part of the body, and requiring use of an IV administration of
contrast media material. The examination can be either a classical CT or an interventional radiology
CT procedure. The participants may be either inpatients or ambulatory care patients.
This review will not consider studies investigating extravasations in the framework of chemotherapy,
anaesthesiology or parenteral nutrition. Indeed, the products used present a very different composition
and thus different properties (e.g. viscosity and toxicity) compared to contrast media.
Types of intervention(s)/phenomena of interest
This review will consider studies that evaluated interventions or protocols which may prevent
extravasation of contrast media or reduce its severity. Accordingly, it will include any strategies, related
to:

The contrast agent (volume, concentration, viscosity, temperature)
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
The injection per se (patient injection site, preparation room)

The material used for injection (catheter gauge, cannulas, butterfly, venflon)

The apparatus used (detection device: ultrasound, radiofrequency)

The healthcare professionals (profession, skills)

The patient risk assessment by the radiology personnel (medication, morbidity, language).
The comparators of this study will be either other interventions -such as a different contrast agent,
another cannula- or usual care -such as the absence of preparation room or detection device.
Types of outcomes
This review will consider studies that include the primary and secondary outcomes described below.
Primary patient outcomes will include:

Extravasation frequency

Extravasation volume

Extravasation severity, including inflammatory reactions, necrosis, pain

Complications, including plastic surgery and amputation
Secondary outcome measures will include:

Diagnostic value and accuracy

Workflow

False positive detection of extravasation. This outcome is particular to the interventions using
detection device.
Types of studies
This review will consider both experimental and epidemiological study designs including randomized
controlled trials and non-randomized controlled trials. In the absence of these trials, other study
designs, such as quasi-experimental, prospective and retrospective cohort studies, case control
studies and analytical cross sectional studies will be considered for inclusion. In the absence of
significant analytical literature on this topic, then descriptive epidemiological study designs including
case series, individual case reports and descriptive cross sectional studies will be considered for
inclusion.
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy
will be utilised in this review. An initial limited search of MEDLINE and CINAHL will be undertaken
followed by analysis of the text words contained in the retrieved titles and abstracts and of the index
terms used to describe the article. A second search using all identified keywords and index terms will
then be undertaken across all included databases. Thirdly, the reference list of all identified reports and
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articles will be searched for additional studies. Studies published, in English and French, from 1980 to
June 2014 will be considered for inclusion in this review.
The databases to be searched will include: CINHAL, Embase, Medline, The Cochrane register of
controlled trials, Web of knowledge, PsycINFO.
The search for unpublished studies will include: ProQuest Dissertation & Theses Database,
TripDatabase, Clinical trials
Initial keywords to be used will be:
Extravasation, contrast media, computed tomography, prevention, healthcare professionals,
frequency, volume, complications
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity
prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs
Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I).
Any disagreements between the reviewers will be resolved through discussion, or with a third reviewer.
Data collection
Data will be extracted from papers included in the review using the standardized data extraction tool
from JBI-MAStARI (Appendix II). The data extracted will include specific details about the
interventions, populations, study methods and outcomes of significance to the review question and
specific objectives. Authors of primary studies will be contacted for missing information or to clarify
unclear data.
Data synthesis
The primary objective is to pool all quantitative data, where possible, for statistical meta-analysis using
JBI-MAStARI. All results will be subject to double data entry by the two reviewers. Effect sizes
(expressed as an odds ratio for categorical data) and weighted mean differences (for continuous data)
and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed
statistically using the standard Chi-square test and also explored using subgroup analyses based on
the different study designs included in this review. Where statistical pooling will not be possible, the
findings will be presented in narrative form including tables and figures to aid in data presentation
where appropriate.
Conflicts of interest
There is no conflict of interest regarding this systematic review.
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Appendix I: Appraisal instruments
MAStARI appraisal instrument
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Appendix II: Data extraction instruments
MAStARI data extraction instrument
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