RT9 FINALS

CONTRAST

• It is the difference in optical density between the

light and dark
areas of radiographs

• It depends on absorption coefficients of different

tissues
What are the factors that determine contrast?

Beam Attenuation

CONTRAST MEDIUM

• Agent that enhances

differences between
anatomical structures. Factors that determine/affects contrast

• Administered to the patient in

order to improve visualization
of an organ, tissue, or
pathologic condition.
 ✓Non-toxic
✓Stable compound
✓Concentrated in the required area when injected
✓Rapidly eliminated when necessary
✓non-carcinogenic
✓Appropriate viscosity for administration
✓Tolerated by the patient
✓Cost-effective.

TYPES OF CONTRAST MEDIA

BARIUM SULFATE

Universal contrast media used for radiographic

examinations of the gastrointestinal tract.
Characteristics make barium solutions suitable for
imaging of the gastrointestinal tract:

o High atomic number (56) producing good

radiographic contrast
o Insoluble in water
o Non-absorbable, non-toxic
o Stable
o Relatively inexpensive
o Excellent coating properties of the
gastrointestinal mucosa

Disadvantage:
Requirements of ‘the ideal’ contrast medium and
types of contrast agent Ideal contrast medium
• Subsequent examination may be difficult as once
should fulfil certain requirements for safe and
in the intestinal tract, it takes time to clear.
effective application. It should be:
• Overlapping of barium filled bowel loops
• Poor distention
✓Easy to administer
• Time consuming
• Precautions
• Adequate hydration post-examination
• Contraindications:
• Suspected perforation
• Suspected fistula
• Suspected partial or complete stenosis
• Paralytic ileus
• Hemorrhage in the gastrointestinal tract
• Toxic megacolon
• Prior to surgery or endoscopy
• If the patient has had a recent gastrointestinal wide
bore biopsy (usually within 3–5 days) or a
recent anastomosis

Thin barium
➢ For upper GI studies, small
bowel follow through, barium
enema
➢ 40% BaSO4 solution.

Thick barium
ORGANIC IODIDE
➢ For double contrast studies
➢Exist in majorly in liquid form
➢ 85% BaSO4 solution
➢Soluble in water
➢Quickly absorbed and excreted by the body
➢Does not stay within cavity for long
➢Sub-type:
➢HOCM
➢LOCM
➢IOCM

RADIOGRAPHIC PARADOX

o Aspiration of barium solutions during upper

gastrointestinal tract imaging.
 • When in solution, it dissociates into iodine and
Sodium/Meglumine
• 5-8x osmolality of the plasma
• More likely to cause adverse reaction
• Examples:
• Diatrizoate Sodium/Meglumin (Urografin)
• Iothalmate Sodium/Meglumin (Conray)

LOW OSMOLAR CONTRAST MEDIA

OSMOLALITY
• Advance over HOCM
• Concentration of dissolved particles in a • More expensive
solution • Two methods to reduce the concentration of
dissolved particles:
• IONIC DIMERS LOCM
- CM dissociates in solution but less particles
- example: IOXAGLATE
• NON-IONIC MONOMERS LOCM
- CM does not dissociate into particles
“When CM with as osmolality far greater than - example: IOPAMIDOL
that of the body is introduced to the body, the • Less likely to cause reaction
osmotic pressure will cause the water to move from
ISO-OSMOLAR CONTRAST MEDIA
the low concentration body fluid to the high
osmolar CM”.
• Osmolality similar to that of plasma.
• Iodixanol (Visipaque) is the only agent currently
in this
class.
• Fewer side effects in patients undergoing
interventional
procedures
• Fewer adverse cardiac events compared with
LOCM.
• Reduction in nephrotoxicity with this agent

INDICATIONS FOR CONTRAST MEDIA

Water soluble contrast media for oral Use

Gastrografin

HIGH OSMOLAR CONTRAST MEDIA • For CT scan of the abdomen and pelvis
• For GIT evaluation in cases of
• Older, less expensive iodine based CM • Suspected perforation
• Possess high concentration of dissolved particles • Suspected anastomotic leakage
• Suspected intestinal obstruction

Water soluble contrast media for IV Injection

Water soluble contrast media used for any canal

• Intravenous urography , IVP
or duct opacification
• All CT examination using contrast material
• CHEST , ABDOMEN ,BRAIN
• Evaluation of the salivary gland (Sialography)
• CT angiography of any vessel
• Injection in any external opening in the skin
• Carotid
(Fistulography)
• Pulmonary
• Evaluation of the urethra and urinary bladder
• Aorta
(Cystourethrography)
• Lower limb vessels
• Evaluation of the uterus and tubes
• Coronary vessels
(Hysterosalpingography)

Water soluble contrast media for Injection in any

tube inserted surgically

• T- tube cholangiography for

assessment of the bile ducts
Water soluble contrast media for intrathecal • Percutaneous nephrostomy for renal evaluation
injection • Percutaneous cystography for evaluation of the
urinary bladder
Iohexol
• Cervical myelography
• Dorsal myelography
• Lumbar myelography
Oily contrast media for certain investigations

Lipiodol ultra - Fluida

• HSG
• Fistulography
• Some cases of swallow
• Suspected corrosive stricture
• Suspected esophageal perforation
• Suspected surgical anastomotic leakage

Barium examinations of the GIT

• Barium swallow (Esophagus)

• Barium meal (stomach)
• Barium enema (colon )
Contrast Media available in the PHILIPPINES

Gadopentetic Acid/ Gadodiamide

1. Mode of action:
• An ionic gadolimium chelate, paramagnetic
contrast media for MRI.
• Shortens the relaxation time of water protons in
the plasma leading to increase in
signal intensity, thus enhancing the image contrast
between tissues.
2. Administration & Dosage:
• Intravenous
• 0.1 mmol/kg (0.2 mL/kg), given at a rate not
exceeding 10 mL/15 sec

3. Distribution:
• Rapidly distributed into the extracellular space.
• Crosses placenta and enters breast milk in small
amount. Volume of distribution:
Approx 0.266 ± 0.043 L/kg.

4. Excretion:
• Via urine (approx 91% as gadopentetate). Iohexol
Elimination half-life: 1.6 ± 0.13 hr 1. Mode of action:
• Non-ionic, monomeric, triodinated, water-soluble
5. Indication radiographic contrast
• Cranial, spinal and whole body MRI imaging medium.
• Allows visualization of internal body structures by
6. Contraindications: opacifying the path of its
• Hypersensitivity. flow.
• Acute kidney injury, Severe renal impairment
(GFR <30 mL/min/1.73 m2). 2. Administration:
• Neonates <4 week. • Intravenous, Intra-arterial, Intracavitary,
• Patient in perioperative liver transplantation Intraperitoneal, Intrauterine, Urethral,
period. Intrathecal, Oral, Rectal

7. FDA category: 3. Absorption:

•C • Poorly absorbed in oral
• Time to peak plasma iodine concentration: 15-120
8. Adverse reaction: seconds (rapid IV inj)
• Gadolinium retention, extravasation reactions (e.g.
thrombosis, skin and soft tissue 4. Distribution:
necrosis) • Crosses the placenta
• Inj site reactions (e.g. pain, oedema, irritation) • Enters breast milk (small amounts)
• Nausea, vomiting, dysgeusia, Headache, dizziness,
Hot or cold sensation 5. Excretion:
• Potentially fatal: Nephrogenic systemic fibrosis. • Via urine (approx 88-90% as unchanged drug
Rarely, hypersensitivity [intravascular, intrathecal]
 • Acute kidney injury, including renal failure
• Thyroid storm
• Transient hearing loss (following myelography)
• Inj site reactions (e.g. pain, oedema, irritation)
• Potentially Fatal: Hypersensitivity reactions,
including anaphylaxis. Rarely, CV reactions (e.g.
hypotension, shock, cardiac arrest), thromboembolic
events resulting in MI or stroke.

Iopamidol

6. Indication
• Contrast-enhanced computerised tomography
• GIT examination, Digital subtraction angiography,
Myelography, Sialography, Hysterosalpingography,
Herniography, Voiding cystourethrography
1. Mode of action:
• Nonionic iodinated radiographic contrast medium.
• Allows visualization of internal body structures
through opacification of vessels in the path
of its flow
2. Administration & Dosage:
• Intravenous, Intra-arterial, intrathecal, Oral, Rectal

7. Contraindications: 3. Absorption:
• Hypersensitivity. Manifest thyrotoxicosis • Rapidly absorbed into the bloodstream from CSF
after intravascular administration.
8. FDA category: • Very poorly absorbed after oral or rectal
•B administration.

9. Drug Interaction: 4. Distribution:

• May lead to transient renal impairment and
precipitate
lactic acidosis in diabetics who are taking
metformin
• Distributed throughout the extracellular fluid but
does not enter cells.
• Crosses the placenta.
5) Excretion:
• Intravascular: Mainly via urine (approx 50% as
unchanged drug); faeces (approx 1%).
Elimination half-life: Approx 2 hours.

6. Indication
• Contrast-enhanced computerized tomography
• Cerebral arteriography, Coronary arteriography
and ventriculography, Computed tomographic
cisternography, Myelography, Excretory urography

10. Adverse reaction: 7. Contraindications:

• Severe cutaneous adverse reactions • Intravascular: Known or suspected
• Hypertensive crisis hypersensitivity to contrast media.
• Angiography in patients with homocystinuria. • Coronary arteriography and left ventriculography,
• Intrathecal: Known or history of epilepsy. Aortography and visceral angiography, Excretory
urography
8. FDA category:
•B 6. Contraindications:
• Intrathecal administration
9. Drug Interaction:
• May precipitate lactic acidosis in diabetics who 7. FDA category:
are taking metformin •B
• Potentially Fatal:Increased risk of seizures with
drugs that may lower the seizure threshold 8. Drug Interaction:
(e.g. phenothiazine derivatives, TCAs, MAOIs, • May precipitate lactic acidosis in diabetics who
CNS stimulants, analeptics, antipsychotics) are taking metformin

10. Adverse reaction: 9. Adverse reaction:

• Significant: Acute kidney injury (e.g. renal
failure), extravasation, seizures,
electrolyte imbalance
• Potentially Fatal: Anaphylaxis, StevensJohnson
syndrome, toxic epidermal
necrolysis, erythema multiforme
• Significant: Extravasation, acute kidney injury,
renal failure, severe cutaneous adverse reactions
• Potentially Fatal: Anaphylactic reactions. Rarely,
thromboembolic events.

Iopromide

1. Mode of action:
• Iopromide is a nonionic iodinated radiographic
contrast medium.
• Allows visualization of internal body structures by
opacifying the path of its flow

2. Administration
• Intravenous, Intra-arterial

3. Distribution: Iodixanol
• Rapidly distributed in the extracellular fluid.
Volume of distribution: 16 L. Plasma protein 1. Mode of action:
binding: 1%. • Organically bound iodine absorbs radiation in the
blood vessels/tissues when it is
4. Excretion: injected.
• Via urine (97% as unchanged drug); faeces (2%).
Elimination half-life: 2 hours. 2. Administration :
5. Indication • Intravenous, Intra-arterial, intrathecal,
• Contrast-enhanced computerized tomography Intracavitary, Oral, Rectal

3. Distribution:
• Rapidly distributed in the body with a mean
distribution half-life of approximately 21
minutes.

4. Excretion:
• The mean elimination half-life is approximately 2
hours
• Excreted mainly through the kidneys (80% of the
administered dose is recovered
unmetabolized in the urine within 4 hours and 97%
within 24 hours after intravenous
injection in healthy volunteer)

5. Indication
• Contrast-enhanced computerised tomography
• Angiography, Arteriography, Myelography,
Excretory urography, Arthrography, HSG

6. Contraindications: PATIENT SELECTION AND PREPARATION

• Hypersensitivity to the active substance or to any STRATEGIES BEFORE CONTRAST
of the excipients. Manifest thyrotoxicosis. MEDIUM
ADMINISTRATION
7. FDA category:
•B The approach to patients about to undergo a
contrastenhanced examination has four general
8. Drug Interaction: goals:
• Use of iodinated contrast media may result in a
transient impairment of renal function and this may 1) To ensure that the administration of contrast is
precipitate lactic acidosis in diabetics who are appropriate for the
taking metformin. patient and the indication;
2) To balance the likelihood of an adverse event
9. Adverse reaction: with the benefit of
• Significant: Acute kidney injury the examination
• Potentially Fatal: Hypersensitivity reaction 3) To promote efficient and accurate diagnosis and
treatment
4) To be prepared to treat a reaction should one
occur

Achieving those goals depends on:

• Obtaining an appropriate and adequate history for

each patient
• Considering the risks and benefit of using or Adverse reaction to IV contrast media and
avoiding contrast Treatment
medium
• Preparing the patient appropriately for the
examination
• Having equipment available to treat reactions
• Ensuring that personnel with sufficient expertise
are available to treat
severe reactions.

What should we obtain from patient’s history?

• Age and Gender

• Comorbidities:
✓Allergy
✓Asthma
✓Renal Insufficiency
MILD REACTIONS
✓Cardiac Status
✓Anxiety
• Mild Signs and symptoms are self-limited without
✓Hyperthyroidism evidence of progression.
• Maintenance medications • May give symptomatic acute therapy.
✓Beta blockers
✓Metformin
• Previous imaging procedure
• Dentures, Pacemakers, Implants
• Handedness

METFORMIN

• Metformin is excreted unchanged by the kidneys,

probably by both
glomerular filtration and tubular excretion.
• Metformin seems to cause increased lactic acid
production by the MODERATE REACTIONS
intestines.
• Any factors that decrease metformin excretion or • Moderate Signs and symptoms are more
increase blood pronounced and commonly require medical
lactate levels are important risk factors for lactic management.
acidosis. • Some of these reactions have the potential to
• Metformin should be withheld temporarily for become severe if not treated.
patients undergoing radiological studies using IV
iodinated contrast media.
 5. Defibrillator or automated external defibrillator
(AED)**

• The following minimum medications should be

within or near any room in which contrast media is
to be injected:

SEVERE REACTIONS 1. Epinephrine IM 1mg/1mL (auto-injector or vials

with needle and
• Severe signs and symptoms are often life- syringe for use)
threatening and can result in permanent morbidity 2. Inhaled short-acting beta-agonist (inhaler or
or death if not managed appropriately nebulizer)
3. Anti-histamine (Diphenhydramine)

The following may be considered for inclusion

within or near any room in which contrast media is
to be injected:

1. Normal saline (0.9%) and tubing

2. Syringes and IV cannulas: variety of sizes;
EQUIPMENT FOR CONTRAST REACTION
tourniquets
KITS IN RADIOLOGY
3. Needle(s) for IM drug administration
4. Epinephrine IV 1mg/10mL, 10-mL preloaded
Facilities should be equipped with basic emergency
syringe
equipment and medications needed to assess
5. Atropine IV, 1mg/10mL, 10-mL preloaded
patients and treat contrast reactions:
syringe
6. Corticosteroid IV
1.) One treatment cart designed for both contrast
7. Nitroglycerin sublingual, 0.4 mg tab
reactions and
8. Aspirin per oral, 325 mg (for chest pain where
cardiopulmonary arrest
myocardial ischemia is a consideration)
2.) Equipment that can help assess a patient’s
9. Lasix IV, 20–40 mg (for pulmonary edema)
clinical status
10. Labetalol IV, 20 mg (for hypertensive
3.) Contact phone number of the local emergency
emergency)
response team
11. Dextrose IV, 50% 25g/50mL syringe (for
hypoglycemia)

• The following minimum equipment should be

within or near any room in which contrast media is
to be injected:

1. Access to oxygen
2. Blood pressure and pulse monitor
3. Pulse oximeter
4. Stethoscope
 (HOCM) and low osmolality contrast media
(LOCM). They concluded that LOCM are less
nephrotoxic than HOCM in patients with underlying
renal insufficiency.

• Solomon et al [100] reported no beneficial effects

from the osmotic diuretic mannitol when it was
added to IV saline solution in patients with
or without diabetes mellitus. There was an
exacerbation of renal dysfunction when the loop
diuretic furosemide was used in addition to IV
saline solution. Neither mannitol nor furosemide is
recommended for CI
Contrast-associated acute kidney injury
(CA-AKI)

• Formerly known as post-contrast acute kidney

injury (PCAKI)
• General term used to describe a sudden
deterioration in renal function that occurs within 48
hours following the intravascular administration of
iodinated contrast medium.
• Contrast-induced acute kidney injury (CI-AKI)
(formerly known as contrast-induced nephropathy
(CIN) is a specific term used to describe a
sudden deterioration in renal function that is caused
by the intravascular administration of iodinated
contrast medium; therefore, CI-AKI is a
subgroup of CA-AKI [1-12]. CI-AKI is a causative
diagnosis.
• The diagnosis of AKI is made according to the
KDIGO criteria if one of the following occurs
within 48 hours after a nephrotoxic event (e.g.,
intravascular iodinated contrast medium exposure):

• Barrett and Carlisle [82] reported a meta-analysis

of the literature concerning the relative
nephrotoxicity of high osmolality contrast media
 1. Hand washing
2. Decontamination of equipment
and devices
3. Use and disposal of needles and
sharps safely (no recapping)
4. Wearing protective items
5. Prompt cleaning up of blood and
body fluid spills
6. Systems for safe collection of
waste and disposal

Infection control terminology

Universal precaution • Communicable disease

• Universal precaution are control guidelines
designed to protect workers from exposure to
diseases spread by blood and other body fluids.
• Apply to the care of all patients, irrespective of
their disease state.
➢Or infectious diseases; are caused by
microorganisms such as
bacteria, viruses, parasites and fungi that can be
spread, directly
or indirectly, from one person to another.

• These precautions apply when there is a risk of • Infectious pathogens

potential exposure to: ➢Are caused by pathogenic microorganisms, such
as bacteria, viruses, parasites or fungi; the diseases
1. Blood can be spread, directly or indirectly, from one
2. All body fluids, secretions, and excretions, except person to another
sweat, regardless of
whether or not they contain visible blood
3. Non-intact skin
4. Mucous membranes

Universal precaution

• This includes Infection control terminology

• Nosocomial infections
➢Healthcare-associated infections (HAI)
➢Infection(s) acquired during the process of
receiving health care that was not present during the
time of admission.
➢Microbial source + Transmission + Susceptible
host = Infection
ASEPSIS

• “the absence of potentially

pathogenic micro-organisms”
• Provides measures to prevent the
transfer of microorganisms from health
care personnel and environment to the
patient during a procedure
• Joseph Lister(1827–1912)
➢Father of Modern Surgery
➢He was the first to apply the science of
Germ Theory to surgery