Radiographic Contrast Media

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Radiographic Contrast Media

• RAD TECH 255
• SPECIAL PROCEDURES
• MERRILLS VOL2
• RTA BOOK CH 19

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Subject Contrast

• Range of differences in the intensity of the
  x-ray beam, after it has been attenuated by the
  subject (patient).

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Low Subject Contrast

• What can be done to attain medical information-
• see the difference between muscle, organs or
  vessels
• Define and outline
• organ structure and function

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Contrast media

• Defines subtle differences in subject contrast
• Increases atomic number of area injected
• Results in a SHORTER scale of subject contrast

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Purpose of Contrast Media

• To enhance subject contrast or
• render high subject contrast in a tissue that
  normally has low subject contrast.

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Atomic Number

• Fat 6.46
• Water 7.51
• Muscle 7.64
• Bone 12.31

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Radiographic Contrast Influenced by

• Radiation Quality (KVP)
• Film Contrast
• Radiographic object (Patient)

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KVP TYPE OF CONTRAST USED DETERMINES KVP RANGE

• BARIUM 90 120 kVp
• IODINES 70 80 kVp
• (Ionic / Nonionic Water or Oil)

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INJECTABLECONTRAST MEDIAfor RT 255 procedures

• INVASIVE PROCEDURES
• The o-grams

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ALWAYS TAKE A SCOUT BEFORE CONTRAST
INJECTION v PATHOLOGY v TECHNIQUE v PREP
PRIOR CONTRAST v POSITIONING
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SPECIAL o-grams

• Venogram
• Arthrogram
• Sialogram
• Myelogram
• Arteriogram
• Angiogram
• Galactogram
• Hystersalpingogram.. etc

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CONTRAST INJECTION
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DOUBLE CONTRAST WITH IODINE - HIP Arthorgram
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To check fertility
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LYMPHANGIOGRAM
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Galactography - Breast Duct
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Cerebral Angiogram
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SPECIAL PROCEDURESARE INVASIVE

• ALWAYS GET PATIENTS HISTORY AND CONSENT BEFORE
  BEGINNING
• OR GIVING ANY CONTRAST MEDIA

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CONSENTS

• SIGNED AND WITNESSED
• AFTER PROCEDURE HAS BEEN EXPLAINED
• CHECK DEPARTMENT PROTOCOL
• WHOS RESPONSIBLE ??????

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CONSENTS

• ASSAULT
• verbal threat of harm
• BATTERY
• Unlawful touching - unauthorized treatment
• X-RAY TAKEN ON WRONG PATIENT
• FALSE IMPRISONMENT
• Restraints require permission
• from patient or authorized person

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BLOOD WORK LAB TESTS to check function of
kidneys prior to injection of contrast

• WATCH THE UPPER LIMITS
• BUN BLOOD UREA NITROGEN
• Merrills pg 214 range is 8 to 25
• pg 242 range is 10 - 20
• always check with RAD when level above 20
• CREATININE levels range
• pg 214 (0.6 - 1.5) pg 242 (0.05 - 1.2)
• always check with RAD when level above 1.2
• Indicates function of kidneys
• Diseases / dehydration / kidney failure

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EGFR (new test)

• Estimated
• Glomerular
• Filtration
• Rate
• More advanced test for
• CREATININE levels

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Review of Contrast Agents

• Types of Contrast
• Routes of Adminstration
• Chemical Components

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Contrast Media changes the density of the organs
Therefore changing the Subject contrast will
change the Radiographic contrast and film
contrast May need to INCREASE TECHNIQUE FROM
SCOUT IMAGE
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Contrast Media (review)

• Negative contrast
• (AIR OR CO2)
• Radiolucent
• Low atomic material
• Black on film

• Positive contrast
• (all others)
• Radiopaque
• High atomic material
• White on film

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Types of Contrast Media

• Radiolucent-
• negative contrast agent
• x-rays easily penetrate
• areas- appear dark on films
• Negative Contrast Media
• Air and gas
• complications
• emboli-air pockets in vessels
• lack of oxygen

• Radiopaque-
• positive contrast agent-
• absorbs x-rays
• appears light
• Positive Contrast Agents
• BARIUM
• IODINES
• Both - can be used in same study

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2 BASIC TYPESOF CONTRAST material

• BARUIM Z 56
• NON WATER SOLUABLE
• GI TRACT ONLY INGESTED OR RECTALLY
• KVP 90 120

• IODINE Z 53
• WATER SOLUABLE
• POWDER
• LIQUID
• INTRAVENOUS OR
• Intrathecal
• GI TRACT
• Also OIL based
• KVP BELOW 90

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Methods of Administrationof Contrast Material

• INGESTED
• (ORAL)
• RETROGRADE
• AGAINST NORMAL FLOW
• INTRATHECAL
• Spinal canal
• PARENTERAL (IV, Intrathecal)
• Injecting into bloodstream
• (anything other than oral)

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Contrast media for SPECIAL PROCEDURES

• Diagnostic agents
• that are injected into
• Circulatory System, Joint Spaces, Ducts
• Body orifices/organs uterus, breast,
• salivary lymph glands

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BARIUM a review

• BARUIM SULFATE
• Not used in Special Procedures

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Barium Sulfate

• High atomic number
• Not soluble in water
• Used to coat the lining of organs
• Supplied in different thicknesses
• Used
• Esophogram, UGI, Small Bowel,Lower GI or BE

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Ba ADVERSE REACTIONS

• BARIUM INERT
• SUSPENSION MAY CAUSE ALLERGY
• OCG TABLETS (IODINE) ALLERGY
• AFTER EXAM MAY SOLIDIFY DIFFICULT TO EVACUATE
• INCREASE FLUIDS, MILD LAXATIVE
• EXTRAVASATION OF CONTRAST INTO PERITONEUM

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Extravasation of BA in abd
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Ingested CONTRASTGastrografin or Hypaque

• High atomic
• Close to iodine
• Water soluble
• Similar usage as Barium

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GASTROGRAFINAdverse Reactions

• Water soluble, safe in the abdominal cavity
• Safe to use if perforation is suspected
• Very harmful to the lung tissue
• Do not use if aspiration is possible

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Gastro Pathology present

• Bowel
• Obstruction
• Note contrast
• Seen in kidneys as well

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IODINEIONIC OR NON IONIC

• WATER OR OIL BASE

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IODINATED CONTRASTiodine z 53

• WATER BASED
• INJECTED
• VESSELLS/DUCTS
• INGESTED
• Organ function/flow
• OPEN WOUNDS

• OIL BASED
• INJECTED
• NEVER VESSELLS
• ONLY DUCTS
• NOT INGESTED
• OPEN WOUNDS

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INJECTION OF IODINEinto Vessels

• ALWAYS A WATER BASED IODINATED COMPOUND
• BOLUS INJECTION
• INFUSION DRIP

• IONIC VS
• NON IONIC
• CONTRAST
• 50 -70 CONCENTRATE

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IODINE WATER BASED CONTRAST

• IONIC
• LESS
• MORE REACTIONS

• NON IONIC
• MORE
• LESS REACTIONS

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CONTRAST MEDIAIODINE

• is either IONIC or NON-IONIC
• Osmolarity
• Of Particles (Cations And Anions -)
• In Solution Per Kilogram Of Water
• High Osmolarity
• more Cations And Anions
• Can Upset Homeostasis
• Nonionic Have No Charged Particles

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Contrast Agents

• IONIC
• High Osmolality (Higher risk of complications)
• Diatrizoate sodium (Hypaque)
• Iothalamate meglumine (Conray)

• NON-IONIC
• Low Osmolality (Lower risk of complications)
• Gadodiamide (Omniscan)
• Iodixanol (Visipaque)
• Iopamidol (Isovue)
• Iopromide (Ultravist)
• Ioversol (Optiray)

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• More money
• Less reactions

• Less money
• More reactions

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OIL BASED

• IODINECONTAST
• Instilled in ORGAN

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Oil Based Iodine

• Fatty Acids
• Insoluble in water
• White on the radiograph Radiopaque
• Uses
• Broncography (lungs)
• Tear ducts
• Salivary glands
• Lymphatic system
• Hysterrosalpingogram
• Galactography (breast ducts)
• FAT EMBOLUS IF IT GETS INTO
• BLOOD VESSEL

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Newer Contrast Agents Balance Safety and
Visualization
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CONTRAST MEDIACHEMICAL PROPERTIES

• TRIIODINATED COMPOUNDS
• BASED ON THE BENZOID ACID RING
• IODINE IS USED DUE TO THE HIGH ATOMIC NUMBER

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CONTRAST MEDIA

• IONIC CONTRAST

• NON IONIC CONTRAST

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Iodine Contrast Material

• Non-Ionic Contrast
• Less patient allergic reactions

• Ionic Contrast
• Anion -
• Cation
• More patient allergic reactions
• Ionic contrast media dissociates into two
  molecular particles in blood plasma
• Causing pt reactions

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Iodine Contrast Material

• ANIONS
• - CHARGE IONS
• Responsible For Stabilizing And Detoxifying The
  Contrast Media

• CATIONS
• CHARGED IONS
• Responsible For Increasing The Solubility Of The
  Medium

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What contributes to discomfort, side effects,
reactions

• VISCOSITY (thick, sticky)
• thicker harder to inject, more heat and vessel
  irritation (higher greater viscosity)
• Warming contrast will help
• TOXICITY - (higher greater viscosity)
• MISCIBILITY - easily mixes with blood

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Iodinated CONTRAST AGENTSAdverse Reactions

• Osmolarities higher than body fluids
• Viscous
• Greater chance for contrast reactions
• Anaphylatic shock is the most severe

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CONTRAST MATERIALADVERSE REACTIONS

• ALWAYS GET PATIENTS HISTORY BEFORE ANY CONTRAST
  MEDIA IS GIVEN
• SEE Ch. 19 Table 19-7 pg 296
• Carlton Pt Care (3RD ed)

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General Factors for Contrast Reactions

• Nonionic vs ionicRisk FactorsSeverity of
  ReactionsRenal toxicity
• Glucophage Diabetic?
• Screening Creatinine
• Pretreatment

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CONTRAST MEDIA ADVERSE REACTIONS

• RISK
• Any foreign substance introduced in the body
• Chance the body will react negatively to the
  material
• Minor to Life Threatening
• Minor 5 Major 0.1

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GOOD PATIENT HISTORY

• Kidney problems
• Diabetes
• Heart conditions
• Allergies
• Asthma

• Previous reaction
• Current medications
• Beta Blockers
• Antihypertensive medications
• VITAL SIGNS

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CONTRAST REACTIONS

• General
• gt 10 million diagnostic procedures
• per year
• Conventional ionic contrast reactions - 10
• 1 in 1000 severe

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Contraindiatons for Contrast

• Renal Failure (Check BUN Creatinine)
• Elevated levels could cause renal shutdown
• Anuria (no urine production)
• Asthma (possible allergies)
• Hx of Contrast Allergy / Reactions
• Diabetes - get a hx of medications taken
• glucophage must be stopped 48 hrs before contrast
  injection
• Multiple Myeloma

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MORE Risk Factors for Contrast Reaction

• Older patient age
• Allergic Rhinitis, medication or Food Allergy
• Cardiovascular disease

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CONTRAINDICATIONS

• Pregnancy (risk of fetal Thyroid toxicity)
• Radiation concerns
• Allergic Reaction
• Pathologic Conditions
• Infection

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Allergic to Iodine

• General Rule
• No Iodine Contrast will be given
• Pre medication is available
• May or may not react if previous iodine given

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Aseptic Technique for injection
betadine scrub Contains iodine
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REACTIONS Treatment

• USUALLY WITHIN FIRST 5 MINUTES
• Nausea Vomiting Urticaria
• Hypotension (bradycardia)
• Hypotension (tachycardia)
• Bronchospasm
• Anaphylactoid
• Seizures
• Extravasation

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Catagories of Adverse ReactionsMILD

Ch. 19 pg
297 Pt Care

• nausea, vomiting
• Uticaria (hives) rash itching
• Flush face feeling of warmth
• Headace, Chills, Anxiety
• Diaphoresis
• Treatment does not usually get worse
• Watch patient and reassure
• (cool cloth on forehead, emesis basin

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Catagories of Adverse ReactionsMODERATE

Ch. 19
pg 297 Pt Care

• Hypotension (bradycardia)
• Hypertension (tachycardia)
• Dyspnea
• Bronchospasms /wheezing
• Laryngeal Edema
• TREATMENT
• Needs immediate treatment GET RN/RAD
• Needs Meds (Keep IV line in)
• could lead to severe reactions

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Catagories of Adverse ReactionsSEVERE

Ch. 19 pg
297 Pt Care

• Laryngeal edema
• Convulsions
• Profound hypotension
• Clincally manifested arrhythmias
• Unresponsiveness
• Cardiopulmonary Arrest
• PROMPT TREATMENT CODE BLUE!

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Rx for REACTIONShave ready on Emergency cart or
Crash Cart

• UTICARIA (HIVES)
• Benadryl (diphenhydramine)
• Vistaril (hydorxyzine)
• Tagament or Zantac
• Facial/Laryngeal Edema/Bronchospasms
• Epinephrine , Oxygen

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Contrast Reactions/MYTHS

• not caused by iodine
• Ionic vs non ionic - binding elements
• not related to shellfish
• not true allergy (no drug-antibody)
• mechanism remains unknown

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Anaphylactoid (idiosyncratic)

• unpredictable
• dose independent
• prevalence 1-2 (0.04 - 0.22 severe)
• fatal 1 in 75,000

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RENAL TOXICITY

• (increased serum creatinine gt 0.5 mg)
• 2-7
• 5 10 x increase with pre-existing renal
  insufficiency
• direct relationship between serum creatinine and
  likelihood nephrotoxicity
• Hydrate 100 ml/hr Normal saline 4 hrs prior to
  procedure, continue for 24 hours

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GLUCOPHAGE

• Pt is DIABETIC oral diabetic agent
• MUST STOP __ DAYS BEFORE EXAM
• withhold drug for 48 hrs after contrast
  administration
• patients with renal insufficiency may develop
  lactic acidosis
• The signs of lactic acidosis are deep and rapid
  breathing, vomiting, and abdominal pain

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PreMedications

• Steroids (Prednisone)
• Benadryl (diphenhydramine)
• Epinephrine

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EXTRAVASATION

• Contrast material has seeped outside of vessel
• Local redness and swelling
• Apply WARM Compress 1st 24 hours
• Cool compress for swelling

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Extravasation of Contrastinto soft tissue of arm
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Contrast leaking from bladder
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SCHEDULING CONSIDERATIONS

• Diabetics first
• (Insulin low blood sugar occurs while fasting)
• After Nuclear Medicine Tests
• (iodine goes to thyroid and will alter results)
• Iodine BEFORE Barium
• BE before UGI ( IVP before BE)
• WATER OIL - BARIUM

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SPECIAL PROCEDURSCONTRAST MEDIA

• ARTHROGRAMS
• Injected into JOINT SPACES
• IODINE (positive contrast)
• WATER soluble
• (Ionic or Non-Ionic)
• AIR (negavitve contrast)

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SPECIAL PROCEDURSCONTRAST MEDIA

• MYELOGRAMS
• Injected INTRATHECALLY
• (into the subarachnoid space)
• Nonionic water-soluble contrast
• (NO IONIC CONTRAST)

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31 y/o male DIESafter Myelogram Procedure

• Myelography is safely performed using
• nonionic water-soluble radiographic contrast
  media intended for this route of administration
• Misadministration of ionic contrast media
  intrathecally can result in a syndrome of spasms
  and convulsions, often leading to death
• ISOVUE M ( 20 or 30 cc)

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mix-up between look-alike vials

• ionic HYPAQUE (diatrozoate meglumine)
• nonionic OMNIPAQUE 300 (iohexol)
• Each type of contrast media should be stored
  separately, based on its use.

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SPECIAL PROCEDURSCONTRAST MEDIA

• SIALOGRAPHY
• injected into Salivary Ducts
• IODINE
• WATER (ionic or nonionic)
• OR OIL BASED
• SINOGRAPHIN (OIL)
• RENOVUE (WATER)

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PATIENT PREP

• COVERED WITH EACH EXAM

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REVIEW SPECIAL PROCEDURSCONTRAST MEDIA

• ONLY Water sol.
• Arthrograms
• Myelograms
• Angio/Arterio grams
• Cardiac Cath
• Venograms

• Water or OIL
• Hysterosalpingogram
• Sialogram
• Lymphangiograms
• Lasts longer may cause
• FAT EMBOLI

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REVIEW (Bontrager
Slides)
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REVIEW

• TYPES OF CONTRAST USES
• ADVERSE AFFECTS OF CONTRAST USAGE
• CONTRAINDICATIONS FOR CONTRAST

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Review Questions

• Ch 19 RTA Book - Pg 373

103

• Contrast media are used in radiographic imaging
  to
• a) increase the radiographic density of the area
  of interest
• b) enhance the subject contrast of the area of
  interest
• c) decrease the radiographic density of the area
  of interest
• d) lower the subject contrast of the area of
  interest

104

• Contrast media are used in radiographic imaging
  to
• a) increase the radiographic density of the area
  of interest
• b) enhance the subject contrast of the area of
  interest
• c) decrease the radiographic density of the area
  of interest
• d) lower the subject contrast of the area of
  interest

105

• Radiographic images that demonstrate few density
  differences define
• a) low subject contrast
• b) high subject contrast
• c) low x-ray photon absorption
• d) high x-ray photon absorption

106

• Radiographic images that demonstrate few density
  differences define
• a) low subject contrast
• b) high subject contrast
• c) low x-ray photon absorption
• d) high x-ray photon absorption

107

• A negative contrast agent will
• a) increase density and is radiopaque
• b) decrease density and is radiopaque
• c) decrease density and is radiolucent
• d) increase density and is radiolucent

108

• A negative contrast agent will
• a) increase density and is radiopaque
• b) decrease density and is radiopaque
• c) decrease density and is radiolucent
• d) increase density and is radiolucent

109

• Perforation of the colon during a lower GI barium
  study may result in complications resulting from
• a) flocculation
• b) bronchospasm
• c) convulsion
• d) extravasation

110

• Perforation of the colon during a lower GI barium
  study may result in complications resulting from
• a) flocculation
• b) bronchospasm
• c) convulsion
• d) extravasation

111

• Depending on the environment of the barium
  sulfate,such as acid in the stomach, the powder
  may have a tendency to clump this is called
• a) flocculation
• b) bronchospasm
• c) convulsion
• d) extravasation

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• Depending on the environment of the barium
  sulfate,such as acid in the stomach, the powder
  may have a tendency to clump this is called
• a) flocculation
• b) bronchospasm
• c) convulsion
• d) extravasation

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• 4. Perforation of the vessel while injecting a
  contrast media may resulting in
• a) flocculation
• b) bronchospasm
• c) convulsion
• d) extravasation

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• Perforation of the vessel while injecting a
  contrast media may resulting in
• a) flocculation
• b) bronchospasm
• c) convulsion
• d) extravasation

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• Barium sulfate
• 1. is filtered by the kidneys
• 2. is absorbed by the stomach
• 3. coats the gastrointestinal lining
• 4. is absorbed by the jejunum

116

• Barium sulfate
• 1. is filtered by the kidneys
• 2. is absorbed by the stomach
• 3. coats the gastrointestinal lining
• 4. is absorbed by the jejunum

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• High atomic number elements absorb x-rays at a
  greater rate than low atomic number elements.
• 1. true
• 2. false

118

• 6. High atomic number elements absorb x-rays at
  a greater rate than low atomic number elements.
• 1. true
• 2. false

119

• Barium sulfate is contraindicated if the patient
  is suspected of having a gastrointestinal tract
  perforation.
• 1. true
• 2. false

120

• Barium sulfate is contraindicated if the patient
  is suspected of having a gastrointestinal tract
  perforation.
• 1. true
• 2. false

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• Radiolucent contrast media
• 1. are positive contrast agents
• 2. appear dark on radiographs
• 3. are composed of elements with high atomic
  numbers
• 4. none of the above

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• Radiolucent contrast media
• 1. are positive contrast agents
• 2. appear dark on radiographs
• 3. are composed of elements with high atomic
  numbers
• 4. none of the above

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• Radiopaque contrast media
• 1. are positive contrast agents
• 2. appear light on radiographs
• 3. are composed of elements with high atomic
  numbers
• 4. all the above

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• Radiopaque contrast media
• 1. are positive contrast agents
• 2. appear light on radiographs
• 3. are composed of elements with high atomic
  numbers
• 4. all the above

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• Each of the following is an example of a
  negative contrast media except
• 1. air
• 2. soda water
• 3. barium sulfate
• 4. gas-producing crystals

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• Each of the following is an example of a
  negative contrast media except
• 1. air
• 2. soda water
• 3. barium sulfate
• 4. gas-producing crystals

127

• An air embolus can form as a complication of
  negative contrast media administration.
• 1. true
• 2. false

128

• An air embolus can form as a complication of
  negative contrast media administration.
• 1. true
• 2. false

129

• An fat embolus can form as a complication of AN
  OIL BASED contrast media administration.
• 1. true
• 2. false

130

• An fat embolus can form as a complication of AN
  OIL BASED contrast media administration.
• 1. true
• 2. false

131

• Ionic contrast media dissociates into two
  molecular particles in blood plasma.
• 1. true
• 2. false

132

• Ionic contrast media dissociates into two
  molecular particles in blood plasma.
• 1. true
• 2. false

133

• Most adverse reactions associated with Ionic
  contrast media are significantly decreased with
  the non-ionic contrast media
• 1. true
• 2. false

134

• Most adverse reactions associated with Ionic
  contrast media are significantly decreased with
  the non-ionic contrast media
• 1. true
• 2. false

135

• Which of the following acute reactions to
  contrast media usually requires no medical
  treatment?
• a) bronchospasm
• b) laryngeal edema
• c) urticaria
• d) convulsions

136

• Which of the following acute reactions to
  contrast media usually requires no medical
  treatment?
• a) bronchospasm
• b) laryngeal edema
• c) urticaria
• d) convulsions

137

• Which of the following acute reactions to
  contrast media usually requires immediate medical
  treatment?
• a) Bronchospasm / laryngeal edema
• b) Nausea Vomiting
• c) Urticaria
• d) Warn flush /metallic taste

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• Which of the following acute reactions to
  contrast media usually requires immediate medical
  treatment?
• a) Bronchospasm / laryngeal edema
• b) Nausea Vomiting
• c) urticaria
• d) Warn flush /metallic taste

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• What can be done for a patient who will receive
  water- soluble iodine contrast media to reduce
  allergic-like effects?
• a) premedicate with steroids and antihistamines
• b) give intravenous fluids
• c) instruct the patient to drink warm salt water
  before the procedure
• d) give a negative contrast agent with the
  iodinated medium

140

• What can be done for a patient who will receive
  water- soluble iodine contrast media to reduce
  allergic-like effects?
• premedicate with steroids and antihistamines
• b) give intravenous fluids
• c) instruct the patient to drink warm salt water
  before the procedure
• d) give a negative contrast agent with the
  iodinated medium

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• When you schedule multiple procedures, what
  examination is usually done last?
• a) thyroid function tests
• b) Upper GI
• c) air-contrast colon (BE-AC)
• d) Intravenous pyelogram (IVP)

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• When you schedule multiple procedures, what
  examination is usually done last?
• a) thyroid function tests
• b) Upper GI
• c) air-contrast colon (BE-AC)
• d) Intravenous pyelogram (IVP)
• It will take the BA the longest to travel through
  the GI tract

143

• When you schedule multiple procedures, using
  contrast media which examination must be done
  first?
• a) thyroid function tests (Nuc Med)
• b) Upper GI
• c) air-contrast colon (BE-AC)
• d) Intravenous pyelogram (IVP)

144

• When you schedule multiple procedures, using
  contrast media which examination must be done
  first?
• a) thyroid function tests (Nuc Med)
• b) Upper GI
• c) air-contrast colon (BE-AC)
• d) Intravenous pyelogram (IVP)
• WHY?

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End of Contrast Media for Special Procedures

• RT 255 -2008