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X-Ray Contrast Media - OVERVIEW, USE AND PHARMACEUTICAL ASPECTS | Ulrich Speck | Springer

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Go Twins! There is no conclusive evidence to indicate that reactions to gadolinium-based contrast media are allergic in nature, as antibodies against contrast media including IgE have only very rarely been demonstrated.

Introducing MRI: Contrast Agents (13 of 56)

Chemotoxic-type effects may also occur and are determined by dose, the molecular toxicity of each agent, and the physiological characteristics of the contrast agents ie, osmolality, viscosity, hydrophilicity, affinity to proteins, calcium-binding properties, and sodium content. Chemotoxic effects of gadolinium-based contrast media are more likely to occur in patients who are debilitated or medically unstable.

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Thanks to the small amounts of contrast medium used for magnetic resonance imaging MRI high osmolality osmotoxicity does not cause shift of fluids from the intracellular to the extracellular space, leading to cell dehydration and an increase in intracellular fluid viscosity precipitating cellular dysfunction like what is seen after exposure to high osmolar iodine-based contrast media.

The vast majority of patients with severe anaphylactoid-type reactions recover if they are treated quickly and appropriately. The first-line drugs and equipment should be readily available in rooms in which either iodine- or gadolinium-based contrast agents are injected. A survey has shown that most departments have these items available. The radiologist should remain near the patient for at least the first critical minutes following contrast medium injection and should remain in the immediate vicinity for the next 30 to 45 minutes.

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If there is an increased risk of an adverse reaction, venous access should be left in place. Important first-line management includes establishment of an adequate airway, oxygen supplementation, administration of intravascular physiological fluids, and measuring the blood pressure and heart rate.

Talking to the patient as you check their pulse rate provides useful initial information: breathing is assessed, the possibility of a vagal reaction bradycardia is determined, and a rough estimate of systolic pressure is obtained a palpable radial artery pulse approximates to a systolic pressure of 80 to 90 mm Hg.

The vasoconstriction induced decreases angioedema and urticaria. Ephedrine is a possible alternative. The preparation should be given intramuscularly only. Intravenous administration of adrenaline by inexperienced staff can be dangerous.

X-Ray Contrast Media - Overview, Use and Pharmaceutical Aspects (Paperback)

Lack of intravenous access is associated with a faster epinephrine administration time. The best site for intramuscular injection is the antero-lateral aspect of the middle third of the thigh. The needle used for injection needs to be sufficiently long to ensure that the adrenaline is injected into the muscle. This reinforces the need for a standard dose such as 0. Below 6 years of age, the Resuscitation Council in UK 18 recommends 0. If there is no improvement in the patient's condition, the intramuscular adrenaline dose can be repeated at about 5-minute intervals by nonspecialists if the specialist resuscitation team has not arrived.

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Hypoxia can be a major complicating factor in all these situations, and can be induced by drugs such as adrenaline used for treating reactions. Oxygen should be used for all patients; a history of chronic obstructive pulmonary disease or emphysema is not a contraindication to starting oxygen therapy for an acute reaction.

X-Ray Contrast Media

H2 antihistamines and H2 receptor blockers have a limited role in treating contrast media reactions. They are used primarily to reduce symptoms from skin reactions. High-dose intravenous corticosteroids do not play a role in the first-line treatment of the acute adverse reaction. However, very high doses of corticosteroids may have an immediate stabilizing effect on cell membranes and may be used in the second-line treatment.

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Standard doses can be effective in reducing delayed recurrent symptoms, which can be observed for as long as 48 hours after an initial reaction. It takes 6 hours before corticosteroids are fully active. Atropine blocks vagal stimulation of the cardiac conduction system. Large doses of atropine 0. Intravascular fluid administration is very important, and it alone has been reported to be the most effective treatment for hypotension. There is no evidence to support the use of colloids over crystalloids in this setting.

For initial resuscitation, 0. Detailed protocols for treatment of nonrenal acute adverse reactions are summarized in Tables 1 adults and 2 children. The recommendations are for immediate treatment in the Department of Radiology. Subsequent management of severe adverse reactions including administration of second-line drugs should be handled by the resuscitation team.

Nausea and vomiting, though usually self-limited, may be the first signs of a more severe reaction. The injection should be slowed or stopped. In severe, protracted cases, injection of an anti-emetic may be used. Treatment is usually not necessary if there are only a few scattered hives or pruritus. However, the patient should be observed closely for other systemic symptoms that may develop, and intravenous access should be maintained. Treatment should be given only if the urticaria is extensive or bothersome to the patient.

Bronchospasm without coexisting cardiovascular problems should be treated with oxygen and inhaled bronchodilators. Using a metered dose inhaler, treatment typically involves 2 to 3 deep inhalations. Adrenaline may be used if bronchospasm is not relieved by the inhaled bronchodilators. Therefore, careful clinical evaluation of the patient before beginning treatment is extremely important to differentiate laryngeal edema from bronchospasm.

Adrenaline is the primary treatment for laryngeal edema. Oxygen administration is also important in the management of this condition. Profound hypotension may occur without respiratory symptoms. Normal sinus rhythm and tachycardia differentiate this reaction from the so-called vagal reaction hypotension and sinus bradycardia. Initially, the patient's legs should be elevated, as this returns about mL of blood to the central circulation.

A total volume of up to mL may be required to reverse the hypotension. Although their exact cause is unknown, vagal reactions seem to be elicited or accentuated by anxiety. Proper recognition of this reaction and the associated bradycardia is vital so that the correct treatment of increasing intravascular fluid volume and reversing the vagal stimulation is used. Elevation of the patient's legs and rapid infusion of intravenous fluids treat the vasodilatation and expanded vascular space.

The bradycardia is treated by intravenous administration of atropine to block vagal stimulation of the cardiac conduction system. Initial treatment includes maintenance of the airway, administration of oxygen, rapid infusion of intravenous fluids, and administration of adrenergic drugs. Adrenaline is the drug of choice. According to the Project Team of the Resuscitation Council in the United Kingdom, adrenaline should never be used intravenously because of the risk of arrhythmia, and subcutaneous administration is not helpful in acute life-threatening situations.

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Hypoxia increases the risk of severe cardiac arrhythmias. Adrenaline should be avoided, if possible, in a pregnant patient experiencing an anaphylactoid reaction with hypotension. During anaphylaxis, tryptase is released from the mast cells into the blood. Blood tryptase levels peak at 1 to 2 hours, and decline rapidly with a 2-hour half-life. Whether or not collapse after contrast medium represented an anaphylactoid reaction may be important to future care of the patient. The UK Resuscitation Council 18 recommends that blood samples for tryptase are taken following suspected anaphylaxis, so that the diagnosis can be established.

The minimum re-commendation is 1 sample 1 to 2 hours after the reaction. Ideally, 2 samples should be obtained—the first once resuscitation is underway, the second at 1 to 2 hours after the reaction, and the third at 24 hours or during convalescence. Prompt recognition and treatment can be invaluable in blunting an adverse response of a patient to gadolinium-based contrast agents and may prevent a reaction from becoming severe or even life-threatening.

Radiologists and their staff should review treatment protocols regularly eg, at 6 to 12 monthly intervals so that each can accomplish his or her role efficiently. If confirmed by others, training might take place at least quarterly. As a matter of fact, knowledge, training, and preparation are crucial for guaranteeing appropriate and effective treatment if there is an adverse contrast-related event.

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