PATIENT CARE

IN CT IMAGING
CONTENTS
• Patient Communication
- benefits of good communication
- barriers to communication
- non-verbal communication
- the speaker’s responsibilities
- the listener’s responsibilities
• Patient Preparation
- protocol selection
- room preparation
- medical history
- laboratory values
- patient education & informed consent
- immobilization devices
- vital sign
• Contrast Media
- contrast media administration
- osmolality, viscosity & ionicity
- contrast media dose
- pregnancy & lactation
- reactions to contrast media
- pre-medications
• Injection Technique
- vascular access
- peripheral venous catheter
- CVAD
- PICC
- methods of contrast media delivery
- drip infusion
- bolus injection (by hand & injector)
 PATIENT
COMMUNICATION
 PATIENT COMMUNICATION
BENEFITS OF
GOOD
COMMUNICATION

“Patients don’t care how much you

know until they know how much
you care”.
Sir William Osler
PATIENT COMMUNICATION
BARRIERS TO COMMUNICATION

• Jargon.
• Language
• Emotional.
• Assumptions.
• Past experiences.
• Fuzzy transmission.
• Receiver distortion.
• Cultural differences.
• Misreading of body language or tone.
PATIENT COMMUNICATION
NON-VERBAL COMMUNICATION

• Visual (facial expression, eye contact, posture, gesture)

• Tactile (touch, handshake, hug, arm around a shoulder)
• Vocal (intonation of a person’s voice)
• Space & image (personal, social, and public distance, personal image)
• Objects or values (surrounding object, e.g., clean waiting room)

“Studies have shown that as much as 90% of the meaning we derive from communication comes from the non-verbal cues that the other person gives”
PATIENT COMMUNICATION
THE SPEAKER’S RESPONSIBILITIES

• Be audible.

• Be aware that your listener may not have understood you.

• Be willing to ask questions of your listener to see whether he or she

understands you.
PATIENT COMMUNICATION
THE LISTENER’S RESPONSIBILITIES

• Let the speaker know whether he or she is inaudible.

• Let the speaker know that you are attentive.

• If the speaker’s message is unclear, let him or her know that you need
a point clarified.
 PATIENT
PREPARATION
PATIENT PREPARATION
Steps taken before the patient performing CT imaging:
i) scheduling the CT examination
ii) selecting the appropriate CT examination protocol
iii) obtaining patient’s medical history
iv) preparing the CT examination toom

• Before the CT examination begins, the CT technologist/radiographer

must check the doctor’s order and read all clinical data provided.
PATIENT PREPARATION
PROTOCOL SELECTION

• The proper selection of CT protocol must be confirmed by radiographer

and review by radiologist/oncologist.

• Sometimes constrained by CT scanner’s capabilities.

• The selection of CT protocol must:

i) answer the clinical question, patient sign & symptom
ii) consider the patient’s ability to tolerate the CT examination
iii) low risk to the patient (radiation dose, contrast media reaction, complications)
PATIENT PREPARATION
ROOM PREPARATION

• CT scanner calibrations and tube warm-up procedures

should be done earlier.

• The CT room should be checked for cleanliness. Sanitized

the CT couch after each patient procedure performed.

• The appropriate equipment & immobilization devices, such

as head holder or foot extension, angle sponges should be
attached and ready.

• Appropriate safety equipment, such as thyroid or breast

shields, lead aprons should be ready for use.
PATIENT PREPARATION
MEDICAL HISTORY

• Medical history might help in accurate CT protocol selection, give radiologist some
diagnostic information & ensure patient’s safety.

• Previous imaging & other medical examination results can help the interpretation of
diseases & select the suitable CT protocol.

• Questions on the medical history regarding renal function, allergies, and thyroid conditions
help to determine whether an iodinated contrast agent will be administered intravenously.

• Administration of intravenous iodinated contrast agents has been reported to cause

increased weakness in myasthenia gravis patients. Some studies reported adverse
reactions to intravenous contrast media in patients treated with interleukin-2.
PATIENT PREPARATION

LABORATORY VALUES

• Blood urea nitrogen (BUN) and serum creatinine provide information about a
patient’s kidney function, which is important if the patient will receive an
intravenous (IV) contrast media.

• Examinations such as CT biopsies and fluid drainage carry the risk of excessive
bleeding. The laboratory values for prothrombin time (PT) and partial
thromboplastin time (PTT) & platelet count provide information about the
blood’s coagulation ability.

• Radiographers must alert if the laboratory values not in the normal range value
and must consult with radiologist or oncologist.
REFERENCE: Computed Tomography for Technologist - a comprehensive text, 2018, Lois E. Romans, Wolter Kluwer.
An example of a patient medical history form
used to collect data for a CT examination

• Myasthenia gravis is a chronic autoimmune, neuromuscular disease that

causes weakness in the skeletal muscles that worsens after periods of
activity and improves after periods of rest.

• Interleukin-2 (IL-2) regulates the activities of white blood cells (leukocytes,

often lymphocytes) that are responsible for immunity (development of the
immune system).
PATIENT PREPARATION
PATIENT EDUCATION & INFORMED CONSENT

• Patient has the right to know about any medical procedure they will
undergo. Most of the information provide by radiographers.

• The following information must be provided to patient:

i) how the procedure is carried out
ii) approximate length of the procedure
iii) whether the contrast media will be given
iv) what is expected from the patient (e.g., remain still, hold breath)
v) any follow-up after the CT examination has been completed
 PATIENT PREPARATION

PATIENT EDUCATION & INFORMED CONSENT

• Basic (or simple) consent involves letting the patient know what you plan to
do and asking them whether they agree is a good practice.

• Written consent from the patient for the CT examination involving

intravenous contrast media or in CT biopsies, is compulsory. It must be
signed by the patient before the procedure.

• For pediatric patients, a parent or legal guardian must sign the consent form.
PATIENT PREPARATION
IMMOBILIZATION

• For patient safety and to improve the quality of the CT examinations.

• Straps are used to protect patients from falling from the CT table and to
remind them to remain still during the procedure.

• Bean bags can be placed alongside lower limbs to prevent motion.

• Head rest & thermoformed mask devices always used in CT simulation.

https://www.medical-professionals.com/en/news/radiation-therapists-ct-simulation/
PATIENT PREPARATION
VITAL SIGN MANAGEMENT

• In first meeting, notice patient’s breathing, skin coloration, and overall health.

• Vital signs are the best early indicators of a physiologic change in a patient.

• Vital signs are:

i) blood pressure
ii) pulse rate
iii) respirations rate
iv) body temperature
REFERENCE: United States Medical Licensing Examination (USMLE)
https://www.youtube.com/watch?v=tUkjjD8nLIo
CONTRAST
MEDIA
CONTRAST MEDIA
• Contrast media fill a structure with a material that has a different density than that of the structure.

• When the agent is of a higher density than the structure it is referred to as a positive contrast media
(appear as radiopaque). Example of +ve contrast media are omnipaque, visipaque, gastrograffin

• When the agent is of a lower density than the surrounding structure it is referred to as a negative
contrast media (appear as radiolucent). Example of –ve contrast media are air or carbon dioxide gas.

• Contrast media administration:

i) intravenously (IV)
ii) orally
iii) rectally
iv) intrathecally (into the subarachnoid space surrounding the spinal cord)
v) intraarticularly (directly into a joint space)
 CONTRAST MEDIA
• Iodinated agents are universally used for a
variety of CT examinations because they
are:
i) water soluble
ii) easy to administer intravascularly
iii) high safety index.

• Iodine atoms in the contrast material are

responsible for this increase in attenuation
(increase 40 – 70 HU).

• The properties of iodinated contrast media

(osmolality, viscosity, ionicity) can be used
as a guide to differentiate the usage
contrast media.
CONTRAST MEDIA
• Osmolality = the number of particles in solution as compared with blood.

• Osmolality is universally recognized as playing a major role in allergic reactions

to contrast media. The higher the contrast media’s osmolality, the more
pronounced the effects of this increase.

• 3 types of contrast media osmolality:

- High-osmolality contrast media (HOCM) – higher (7x) than blood osmolality.
- Low-osmolality contrast media (LOCM) – slightly higher (2x) than blood osmolality.
- Iso-osmolality contrast media (IOCM) – the best, expensive, equal to blood osmolality.
 CONTRAST MEDIA
• Viscosity = the thickness or friction of the fluid as it flows.

• important property that will influence the injectability of

intravascular agents through small-bore needles and
intravenous catheters.

• Brand, temperature, and concentration of the contrast

affect its viscosity.

• Warming a contrast media to body temperature (≈ 37° C)

can reduce viscosity.
 CONTRAST MEDIA
• Ionicity = ability of the molecules to
dissociate (separate/split into smaller
atoms, ions, or molecules).

• Ionic contrast media are composed of

molecules that will dissociate into
ions.

• Non-ionic contrast media do not

dissociate.
CONTRAST MEDIA
CONTRAST MEDIA DOSE

• Different CT scan protocols require different contrast media doses (volume & iodine
concentration). Adequate dose can provide good image quality & lower the risk.

• Factor affecting the contrast media dose are injection rate, delay for injection, level of
patient’s dehydration, size or weight.

• It is unclear how the practice of administering a uniform dose of an IV contrast agent,

regardless of the size of the adult patient, became so well established.

• In most clinical practices, the dose used to perform CT examinations on pediatric

patients is calculated by weight. The most common formula used is 2 mL/kg.
CONTRAST MEDIA
CONTRAST MEDIA (PREGNANCY & LACTATION)

• Once injected, most of the contrast media are excreted by the body nearly exclusively by
the kidney via glomerular filtration.

• In patients with normal renal function, is approximately 2 hours for half of the contrast
media dose to be eliminated.

• There is no proof that contrast agents (ionic & non-ionic) present a risk to the fetus.
However, there is not enough evidence to be certain they pose no risk. Patient education
& informed consent are required.

• Less than 1% (extremely low) of the dose of contrast agent given to the mother is
excreted into breast milk.
CONTRAST MEDIA
REACTIONS TO CONTRAST MEDIA

• It is impossible to predict which patients will have an adverse reaction to intravenously

administered contrast medium. Therefore, CT staff must be trained to respond quickly.
Contrast media reactions can be broadly categorized as mild, moderate & severe.

• Examples of symptoms of a mild reactions are cough, itching, rash (hives), pallor, nasal
stuffiness, minimal swelling in the eyes and face, and facial rash.

• Symptoms of moderate reactions are respiratory difficulties (bronchospasm, dyspnea,

wheezing, mild laryngeal edema), pulse change, hypertension and hypotension.

• Symptoms of severe reactions include substantial respiratory distress, unresponsiveness,

convulsions, clinically manifested arrhythmias, and cardiopulmonary arrest.
CONTRAST MEDIA
REACTIONS TO CONTRAST MEDIA

• Risk factors for reactions to contrast media:

1) previous history of contrast medium reaction
2) asthma
3) allergy
4) drugs or medication (ɞ-blockers, metformin)
5) high-osmolality contrast media (HOCM)
6) myasthenia gravis
7) hyperthyroidism
8) pheochromocytoma
9) perforation of GIT tract
CONTRAST MEDIA
PRE-MEDICATIONS

• There is good evidence that pre-

medications with steroids will reduce
the risk of contrast media reactions.

• Oral administration of steroids seems

preferable to intravenous
administration, and
prednisone/prednisolone and
methylprednisolone are equally
effective.

• Two common oral regimens of pre-

medications are outlined in table.
 INJECTION
TECHNIQUE
INJECTION TECHNIQUE
• The method of injecting contrast media will vary depending on available vascular
access, the type of examination and the specific clinical indications for the
examination.

• These factors will determine whether the injection will be performed by hand or
with the use of a mechanical injector.

• The choose of injection by hand or injector will influence the contrast volume
used, the flow rate at which the contrast will be injected, the delay between
injection and scanning, and whether a saline flush is advantageous.

• A radiologist, radiographer or nurse may administer contrast media.

INJECTION TECHNIQUE
• In addition to standard indwelling
peripheral venous catheters, patients
may arrive with central venous access
devices (CVAD) or peripherally inserted
central catheters (PICC).

• CVAD is a venous catheter designed to

deliver medications and fluids directly
into the superior vena cava.

• PICC is a long catheter that is inserted

through the large veins of the upper arm
and advanced so that its tip is in the
lower third of the superior vena cava.
INJECTION TECHNIQUE
• Methods of intravenous contrast media delivery:
i) Drip Infusion
ii) Bolus Technique

• The drip infusion method is the least effective injection method for
abdominal imaging and cannot produce peak enhancement.

• The bolus technique of contrast enhancement uses scanning after a rapid

injection of contrast media (50 – 200 mL at 1 – 6 mL/s).

• The contrast bolus can be delivered by hand (using syringes) or by a

mechanical injector system.
INJECTION TECHNIQUE
• Advantages of injector in delivering contrast media:
i) precise flow rates and volumes
ii) injections are consistent
iii) injections can be reproduced
iv) programmable, for a wide range of indications

• When using mechanical injector for IV contrast administration

precaution must be taken to reduce the risk of serious extravasation
of the contrast medium into the soft tissue.
https://www.youtube.com/watch?v=F8igOh4COQQ