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Contrast: Where & How is it used? Pamela R. Burgess, BS, RDCS, RDMS, RVT, FASE Presenter Disclosure The following relationship exist related to this presentation: Pamela R. Burgess, BS, RDCS, RDMS, RVT, FASE Lantheous Medical Imaging Speakers Bureau ICAEL Consultant Where are we using contrast? Contrast Enhanced Stress Images Stress Echo Visualization of all walls Increase heart rate on impost images Hyperventilation = Chest wall movement Cardiac Translation movement Impost images acquired in less than 1 minute Results of Contrast Usage with Stress Other Indications for Contrast: Reliable & rapid acquisition of impost images Improved endocardial resolution Greater confidence in wall motion analysis Improved accuracy of diagnosing CAD Transthoracic LV wall motion Thrombus Apical Hypertrophy Doppler Enhancement 1 LV Opacification Other Indications for Contrast Transesophageal Dissection LAA Thrombus Contrast with TEE TEE – R/O Aortic Dissection Aortic Dissection Abd Aorta More Advanced Applications: Alcohol Septal Ablations Decreases gradient in LVOT by direct injection of alcohol into coronary artery that feeds proximal septum Image contrast in septum to evaluate area fed by septal perforator prior to alcohol injection Monitor LVOT gradient 2 Alcohol Septal Ablation Where are our most difficult echos? ICU/CCU - Portables Ventilated Supine in bed Post CT surgery Surgical Incisions Chest Tubes Bandages Critical pathology Limited access to other cardiac imaging Contrast Echo in the ICU Contrast in the ICU Echo test of choice when evaluating CVD No incremental risk for death compared to non contrast echos in the ICU (Kusnetzky et al, Am J Coll How do we make contrast in the ICU efficient? Cardiol, 2008) Pulmonary Hypertension & Unstable Cardiopulmonary Conditions – FDA relaxed BBW from a contraindication to a warning Should still monitor for 30 minutes Most are monitored – ECG & O2 Sat Cardiac Rupture with Contrast Train ICU nurses to administer Digital allows you to send images to lab for MD approval Store agent in medication frig on unit ICU nurses monitor patients after contrast Thrombus with Contrast 3 Apical Patch Clinical Impact of Not Utilizing Contrast Technically Difficult Studies Repeat echos Alterations in patient’s therapy Change in medications Downstream Testing TEE MRI Nuclear Cardiac Catherization Increase LOS Contrast Reimbursement Cost Efficiency of Contrast Hospital Outpatient Medicare Payments Downstream Testing Stress Echo - C8928 - ▲15% - $651; Enhanced Diagnostic Accuracy w/o $451 Transthoracic Echo – C8923 - ▲15%-$651; w/o-$451 Do you Consent for a Contrast Study? Reduced ~33%, with an avg. savings of $122 per patient Reducing false - & + rate Stress Echo Downstream Testing 12% with contrast; 42% with no contrast $238 savings if contrast was used an avoided a stress nuclear study Informed Consent - Definition Is a process of communication between a patient and the healthcare provider that results in the patient’s authorization of agreement to undergo a specific medical intervention. http://www.ama-assn.org/ama/pub/physician-resources/legaltopics/patient-physician-relationship-topics/informed-consent.shtml 4 Informed Consent Present procedural information to the patient in a language they can understand Provide in printed format Exclude: Informed Consent Signature & date Should be written in approximately a 6th Grade reading level May be required by your hospital or office?? Not required in most labs for contrast Varies from institution to institution Check with your Risk Management Department Check institutional policies and procedures & other departments Verbal Consent Verbal Consent Documentation Medical Terms Acronyms Abbreviations Patient informed of risks & benefits of echo contrast, understands and agrees. Another option… Explain the need for contrast Explain the benefit of contrast Requires documentation in patient’s chart or file Patient Contrast Education Sheet Sometimes, Sometimes, the the pictures pictures do do not not show show the the muscle muscle of of your your heart heart well. well. In In this this case, case, we we may may need need to to inject inject aa contrast contrast agent agent into into your your vein vein to to see see your your heart heart better. better. AA staff staff member member will will put put aa very very small small tube tube (an (an IV) IV) in in your hand or arm to give you the contrast agent. Then staff will take your hand or arm to give you the contrast agent. Then staff will take more pictures as the contrast enters your heart. The contrast agent does more pictures as the contrast enters your heart. The contrast agent does not not last last very very long long in in the the body; body; most most of of it it is is removed removed through through normal normal breathing. breathing. Using Using aa contrast contrast agent agent is is considered considered to to be be low low risk. risk. But But risks risks may may occur occur and and may may include: include: Allergic Allergic reaction reaction yBack yBack pain pain yInfection yInfection at at the the IV IV Rarely, Rarely, other other risks risks may may include: include: yHeart yHeart rhythm rhythm changes changes ySeizures ySeizures yDeath yDeath Risks Risks may may be be higher higher in in persons persons with with pulmonary pulmonary hypertension, hypertension, unstable unstable cardiopulmomary conditions, or reactions to ultrasound contrast. cardiopulmomary conditions, or reactions to ultrasound contrast. Standing Order Policy Standardization of Utilization Extension of echo Criteria for Use Defines Who Determines Need 5 Standing Order Pharmacy Issues An order that may be required under certain situations ASE Guidelines – 2 or more missing LV segments Enhance image, pathology, Doppler, etc. Should be included in a policy and procedure Check with your Risk Management Department! Pharmacy Issues Avoiding the Pharmacy – The Benefits Avoid this department! Ordering, storage, and dispensing of contrast agents Creates inefficiencies Extended wait times for contrast Summary Contrast continues to be cost effective Reduces need for downstream testing Helps to decrease LOS Determine your lab’s stand on consents Have standing orders Avoid pharmacy Order the contrast agent you want to use Storage of contrast in the echo lab No wait time, so more efficient Determine how the contrast is administered: Dilution, dosage, etc. Set up your contrast in-services Questions??? 6
