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Contrast media extravasation

Dr David Ferreira and Radswiki et al.

Contrast media extravasation (CMEV) is a well-known complication of contrast-enhanced CT scanning¹. Can also occur in MRI studies, but the complications are rare given the low volume used on it.

CT contrast extravasation occurs relatively infrequently (0.13 - 0.68%), but can have severe side effects associated with skin changes and possible skin necrosis.

Contrast media

Nonionic low-osmolar contrast media is known to reduce the risk of severe soft tissue injury but risk of soft tissue injury is often related to the volume of CMEV¹.

Possible causes related to leakage

The introduction of automated power injection has increased the incidence because power injection may result in extravasation of large volumes in a short period of time², unlike what occurred with manual injection which has direct supervision of the nurse who administers the contrast.
patient-related factors, such as:
- elderly patients;
- emaciated patients;
- edematous patients;
- confused patients.
site of venous access: higher percentage of leakage in the venous access in the back of the hand, wrist, foot and ankle. It is believed that are related to a smaller amount of subcutaneous tissue and the fact that veins are more fragile on these regions.
Gauge venous access: only if are tempted a smaller caliber accesses (over 22G). Study showed that risk of leakage is the same into sizes of 18 and 20G¹.
High-osmolar contrast medium².

Complications

Most extravasations result in minimal swelling or erythema and have no long-term sequelae². A large study found that more than 97% of patients with contrast extravasation had minimal or no injury, and reported that 79% of patients had localized swelling after extravasation, 24% had pain, and 8% were asymptomatic³.

Large volumes (> 50 mL) of high-osmolar contrast media are known to induce significant tissue damage, such as:

skin ulceration;
soft-tissue necrosis;
compartment syndrome.

Treatment

The conduct after an episode of CMEV will vary according to the protocol of each radiology department, and usually includes:

discontinue the contrast infusion and notify the radiologist immediately;
complete the acquisition of images of the CT series;
if the canula is still in place, could be possible to aspirate any residual drug, after remove the IV canula;
apply ice pack to affected area and elevate the affected extremity to reduce swelling.
keep the patient under observation for at least 2 hours;
although our policy requires plastic surgery consultation for all patients whose extravasations involve 100 mL or more of contrast medium;
make contact with the doctor requesting the examination;
it is suggested to follow up the patient by the next few days until the resolution of local edema. Can be accomplished with a phone call to evaluate the regression of the signs and symptoms.
instruct the patient to notify staff if there is:
- increasing swelling or pain over time;
- blistering, ulceration, induration or other skin changes;
- altered tissue perfusion and changes in sensation;