Extravasation of Contrast Medium during CT Scanning Tracking and Reduction of Rate of Extravasation

Extravasation of Contrast Medium during CT Scanning Tracking and Reduction of Rate of Extravasation Poster No.: C-0072 Congress: ECR 2015 Type: Scientific Exhibit Authors: M. S. K. Teo, C. Ong, A. Ying, M. Hng; Singapore/SG Keywords: Contrast agents, Vascular, Veins / Vena cava, CT, CTAngiography, Contrast agent-intravenous, Diagnostic procedure, Safety, Outcomes, Biological effects DOI: 10.1594/ecr2015/C-0072 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 13

Aims and objectives Contrast enhanced CT is performed by the intravenous injection of a large volume of contrast at a high rate by an electric power injector. Extravasation of contrast media is a recognized complication of intravenous administration of contrast. While not common, extravasation of contrast can be serious. It is an adverse outcome for patients. In mild cases, extravasation results in pain and swelling of the surrounding tissues. In severe cases, tissue necrosis and compartment syndrome may occur. Surgical procedures may be required to treat these complications. Extravasation can have potential medico-legal consequences. Fig 1 and 2. The reported extravasation rates during CT range from 0.03 % to 1.3 % in the literature. In 2007, we had an extravasation rate of 0.16 %. We felt the true rate may in fact be higher due to under-reporting. We tracked the rate of extravasation of contrast during CT scan in our department over a period of 7 years and 8 months (Jan 2007 to Aug 2014). In 2008, we implemented several measures to try to reduce the rate of extravasation of contrast. Images for this section: Page 2 of 13

Fig. 1: Extravasation of contrast in the arm. Page 3 of 13

Fig. 2: Extravasation of contrast in the left groin. Page 4 of 13

Methods and materials Our department has 3 Multislice CT scanners. We scan approximately 100 patients per day (26,000 to 30,000 patients per annum). Extravasation injury results from a combination of factors, which include infusion pressure, duration of an indwelling venula and patient factors. By analysing the processes using a flow chart, we were able to identify the most likely causes for extravasation. Fig 3 (Flow Chart) and 4 (Cause and Effect Diagram). One cause of extravasation is the administration of a large volume of contrast medium at a high flow rate using by an electric power injector. In our department, the average dose is approximately 100 ml injected at 1 to 5 mls per second. A venula that is in place for more than 24 hours is known to increase the chance of extravasation, as the vascular integrity diminishes over time, with the venula possibly inducing phlebitis. Thrombus formation at the venula tip may cause obstruction leading to retrograde or perivascular efflux of contrast medium. Patients who have small, fragile veins (e.g. in elderly patients and in those receiving chemotherapy) have a higher risk of extravasation. If that vein ruptures, contrast medium will leak into the surrounding tissues. We summarised the main causes to be addressed using the Pareto Chart. Fig 5 (Pareto Chart). A strategy for change was devised by changing processes, equipment and incorporating the latest technology. The following steps were implemented: 1. Radiographer to stay with patient throughout the injection phase for routine scans Page 5 of 13

A radiographer was required to be present in the room during the entire injection phase of a routine CT scan to closely observe the injection site. This enabled early detection and timely intervention if extravasation was suspected. 2. Extravasation Detection Sensor An extravasation detection sensor system was installed to monitor for extravasation in studies requiring high flow rate and early acquisition of images (i.e. CT angiogram or multiphase CT studies). In these studies, the radiographer has to vacate the room prior to completion of the intravenous injection. The detection sensor is Nemoto Extravasation Sensor System. Fig 6. 3. Replacement of venula exceeding 72 hours duration To prevent extravasation due to an old or thrombosed venula, a CT nurse was appointed to ensure that all venulas inserted more than 72 hours prior were replaced. 4. Standardising larger-sized venula (18G or 20G), to be inserted in the antecubital fossa for CT Angiographic studies The venula size for contrast medium injection was standardised at 18G or 20G, to be positioned preferably at the antecubital fossa, rather than at the wrist or dorsum of the hand. The above strategies were progressively implemented by multiple Plan Do Study Act (PDSA) cycles. Fig 7 (Intervention Chart). Images for this section: Page 6 of 13

Fig. 3: Flow Chart of Process. Fig. 4: Cause and Effect Diagram. Page 7 of 13

Fig. 5: Pareto Chart. Page 8 of 13

Fig. 6: Extravasation detection sensor proximal to venula. Page 9 of 13

Fig. 7: Intervention Chart. Page 10 of 13

Results The rate of extravasation of contrast ranges from 0.03% to 1.3% in the literature. We were able to progressively reduce the rate of extravasation of contrast from 0.16 % in 2007 to 0.07 % in 2014. In the last two years, the rate has stabilised to 0.07 to 0.08 %. Fig 8 and 9. Images for this section: Fig. 8: Chart showing extravasation rate and time point of interventions. Page 11 of 13

Fig. 9: Chart showing extravasation rate over time. Page 12 of 13

Conclusion Extravasation of contrast has potentially serious consequences. It is important to reduce the rate of extravasation. Reducing its rate can be achieved by changing processes and adopting new technology. Staff education and regular audits are important to sustain the achievements. Leadership and motivation at every level is necessary. Personal information References 1. ACR Manual on Contrast Media - Version 9, 2013. American College of Radiology. 2. Wang CL, Cohan RH, Ellis JH, Caoili EM, Wang G, Francis IR. Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69,657 intravenous injections. Radiology 2007;243:80-7. 3. Sistrom CL, Gay SB, Peffley L. Extravasation of iopamidol and iohexol during contrastenhanced CT: report of 28 cases. Radiology 1991;180:707-10. 4. Miles SG, Rasmussen JF, Litwiller T, Osik A. Safe use of an intravenous power injector for CT: experience and protocol. Radiology 1990;176:69-70. 5. Cohan RH, Dunnick NR, Leder RA, Baker ME. Extravasation of nonionic radiologic contrast media: efficacy of conservative treatment. Radiology 1990;174:65-7. Page 13 of 13