OtherCONTINUING EDUCATION

Iodinated Contrast Media and Their Adverse Reactions

Jagdish Singh and Aditya Daftary
Journal of Nuclear Medicine Technology June 2008, 36 (2) 69-74; DOI: https://doi.org/10.2967/jnmt.107.047621

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Tables

  • TABLE 1

    Commonly Used Iodinated Contrast Media

    NameTypeIodine content (mg/mL)Osmolality
    Ionic
     Diatrizoate (Hypaque 50; GE Healthcare)Monomer3001,550 (high)
     Metrizoate Isopaque (Coronar 370; Nycomed A/S)Monomer3702,100 (high)
     Ioxaglate (Hexabrix; Mallinckrodt, Inc.)Dimer320580 (low)
    Nonionic
     Iopamidol (Isovue-370; Bracco Diagnostics Inc.)Monomer370796 (low)
     Iohexol (Omnipaque 350; GE Healthcare)Monomer350884 (low)
     Iodixanol (Visipaque 320; GE Healthcare)Dimer320290 (iso)
  • TABLE 2

    Common Factors Predisposing Patient to Contrast Reactions

    FactorPredisposing characteristic
    AgeInfants and those older than 60 y
    SexFemales > males
    Underlying medical conditionsAsthma, heart disease, dehydration, renal disease, diabetes
    Hematologic conditionsMyeloma, sickle cell disease, polycythemia
    MedicationsNSAIDs, IL-2, β-blockers, biguanides
    Contrast-related>20 mg iodine, faster injection rate, intraarterial, previous contrast reactions

    • NSAIDs = nonsteroidal antiinflammatory drugs; IL-2 = interleukin-2.

  • TABLE 3

    Premedication Protocols for Patients with Previous or Increased Risk for Contrast Reactions

    PremedicationProtocol
    Corticosteroids (any of the following)Prednisone: 50 mg orally, 13, 7, and 1 h before contrast injection
    Hydrocortisone: 200 mg intravenously, 1 h before contrast injection
    Methylprednisone: 32 mg orally, 12 and 2 h before contrast media injection
    Antihistamine (optional)Diphenhydramine: 50 mg intravenously/intramuscularly/ orally 1 h before contrast injection
  • TABLE 4

    General Principles for Managing Contrast Reactions

    PrincipleStrategy
    AAssessment (severity and category of reaction): blood pressure and pulse monitoring, ECG monitor for evaluation of cardiac rhythm
    Assistance (call for it)
    Airway, oxygen
    Access (venous)—secure/improve intravenous lines
    BBreathing (begin cardiopulmonary resuscitation if necessary, bag-valve mask or mouth mask)
    Beware of paradoxical responses (e.g., β-blockers may prevent tachycardia response)
    CCategorize reaction and patient status
    Circulatory assistance, intravenous fluids
    Call cardiopulmonary arrest response team if necessary
    Cardiac output assessment, decreased venous return
    DDrugs: dose and route, do not delay
    Do monitor, assess, and reassure patients

    • ECG = electrocardiogram.

  • TABLE 5

    Management of Common Contrast Reactions

    ReactionEtiologyMonitor…Treatment (28–30)
    Anaphylactoid
     Urticaria (skin rash)Anaphylactoid reactionInitial size with marking and followUsually none; diphenhydramine, 25–50 mg orally/intramuscularly/intravenously; epinephrine (1:1,000), 0.1–0.3 mL subcutaneously/intramuscularly
     BronchospasmAnaphylactoid reactionOxygen saturation, pulse, BPSecure airway; oxygen, 6–10 L/min; metaproterenol/terbutaline inhaler, 2–3 puffs; epinephrine (1:1,000), 0.1–0.3 mL subcutaneously/intramuscularly; epinephrine (1:10,000), 1 mL intravenously (slowly) if hypotensive; call the emergency medical team
     Facial or laryngeal edemaAnaphylactoid reactionOxygen saturation, pulse, BPSecure airway; oxygen, 6–10 L/min; call the emergency medical team if severe; epinephrine (1:1000), 0.1–0.3 mL subcutaneously/ intramuscularly; epinephrine (1:10,000), 1 mL intravenously (slowly) if hypotensive; call the emergency medical team
     Hypotension and tachycardia (fast pulse)VasodilationOxygen saturation, pulse, BPElevate legs 60°; oxygen, 6–10 L/min; rapid intravenous fluids; epinephrine (1:10,000), 1 mL intravenously (slowly); call the emergency medical team
     Hypotension and bradycardia (slow pulse)Vasovagal responseOxygen saturation, pulse, BPElevate legs 60°; oxygen, 6–10 L/min; atropine, 0.6–1 mg intravenously (slowly); repeat to total of 2–3 mg (0.04 mg/kg) if needed; call the emergency medical team
    Nonanaphylactoid
     Cardiac arrhythmiaIonic abnormalities; chemical variationsOxygen saturation, pulse, BP, ECGFollow ACLS* protocols; call the emergency medical team
     HypertensionHistamine release of catecholamineOxygen saturation, pulse, BP, ECGNitroglycerine, 0.4 mg sublingually; nitroglycerine; 2% ointment; phentolamine, 5 mg intravenously for pheochromocytoma; call the emergency medical team
     SeizuresIonic abnormalities; chemical variationsOxygen saturation, pulse, BP, ECGSecure airway; oxygen, 6–10 L/min; diazepam, 5 mg intramuscularly/intravenously; midazolam, 0.5–1 mg intravenously; phenytoin infusion, 15–18 mg/kg at 50 mg/min; call the emergency medical team
     Pulmonary edemaOsmolar changes, causing large fluid volume shiftsOxygen saturation, pulse, BP, ECGSecure airway; oxygen, 6–10 L/min; furosemide, 20–40 mg intravenously (slowly); morphine, 1–3 mg intravenously; call the emergency medical team

    • All medications are to be administered under physician supervision. BP = blood pressure; ECG = electrocardiogram; ACLS = advanced cardiovascular life support.

  • TABLE 6

    Suggested Supplies and Information to Be Made Available

    CategorySpecifics
    Posted informationName and contact information for physician on duty, phone number of emergency response team
    Support apparatusOxygen cylinders, flow valves, tubing, nasal prongs, oxygen masks (adult and pediatric sizes), bag-valve mask, valve masks, endotracheal tubes, laryngoscopes, intravenous fluids (normal saline, Ringer's lactate)
    Emergency and monitoring devicesDefibrillator, ECG, blood pressure/ pulse monitor, pulse oximeter
    MedicationsEpinephrine, 1:10,000, 10-mL preloaded syringe; epinephrine, 1:1,000, 1-mL preloaded syringe; atropine, 1 mg in 10-mL preloaded syringe; β-agonist inhaler; diphenhydramine for intramuscular/intravenous injection; nitroglycerin, 0.4-mg tabs, sublingually

    • ECG = electrocardiogram.

  • TABLE 7

    Risk Factors for and Methods to Prevent Contrast-Induced Nephrotoxicity

    Risk factorMethod
    Advanced age, antibiotics (aminoglycosides such as gentamycin), cardiovascular disease, chemotherapy, collagen vascular diseases, elevated serum creatinine levels (variable levels, 1.3–2.0 mg/dL), dehydration, diabetes (insulin-dependent > 2 y; non–insulin-dependent > 5 y), nonsteroidal antiinflammatory medications, paraproteinemias (myeloma), renal disease, kidney transplantUse the smallest amount of contrast material possible; discontinue other nephrotoxic medications before the procedure; maintain adequate interval between procedures requiring contrast material; maintain hydration (oral, 500 mL before the procedure and 2,500 mL during the 24 h after the procedure; intravenous, 0.9% or 0.45% saline, 100 mL/h, beginning 4 h before the procedure and continuing for the 24 h after the procedure)
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