Contrast media extravasation

Changed by Andrew Murphy, 16 Oct 2016

Updates to Article Attributes

Body was changed:

Contrast media extravasation (CMEV) is a well-known complication of contrast-enhanced CT scanning 1. It can also occur in MRI studies, but the complications are rare given the low volume that are used.

Epidemiology

CT contrast extravasation occurs relatively infrequently, in ~0.5% (range 0.13-0.68%) of cases, but can have severe side effects associated with skin changes and possible skin necrosis. 

Risk factors
  • increased incidence with automated power injection because large volumes can extravasate in a short period of time 2 
    • with manual injection, extravasation is thought less likely, as there is direct supervision of contrast administration
  • patient-related factors
    • elderly patients
    • emaciated patients
    • oedematous 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
    • likely related to a smaller amount of subcutaneous tissue and the fact that veins are more fragile on these regions
  • the gauge of intravenous catheter: only if smaller calibre access (over 22G) is used; risk of leakage is the same for 18G and 20G 1
  • high-osmolar contrast medium 2
    • pre-warming of high-osmolar (370 mg/ml) lowers the viscosity and has been proven to lower the probability of extravasation 5
  • additionally a recently published study "incidence of contrast medium extravasation for CT and MRI in a large academic medical centre: a report on 502,391 injections" showed that 3
    • patients undergoing CT are at higher risk of developing CMEV than MRI patients
    • females and inpatients were also more likely to develop CMEV at both CT and MRI
    • at MRI, CMEV is more likely in patients above the age of 60 years and for those receiving automated power injections

Pathology

Nonionic low-osmolar contrast media is known to reduce the risk of severe soft tissue injury, but the potential for soft tissue injury is often related to the volume of CME 1.

Treatment and prognosis

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

  • discontinue the contrast infusion and notify the radiologist immediately
  • complete the acquisition of images of the CT series
  • attempted aspiration of the extravasation has not been shown to be effective
  • apply an ice pack to the affected area and elevate the affected extremity to reduce swelling
  • keep the patient under observation for at least 2 hours
  • at some institutions, the policy is to require 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 in the next few days until the resolution of local oedema; this 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/or changes in sensation
Complications

Most CMEV results in minimal swelling or erythema and have no long-term sequelae 2. A large study found that >97% of patients with contrast extravasation had minimal or no injury and reported that 79% of patients had localised swelling after extravasation, 24% had pain, and 8% were asymptomatic 4

Large volumes (>50 ml) of high-osmolar contrast media are known to induce significant tissue damage

  • skin ulceration
  • soft-tissue necrosis
  • compartment syndrome
  • -<li>high-osmolar contrast medium <sup>2</sup>
  • +<li>high-osmolar contrast medium <sup>2</sup><ul><li>pre-warming of high-osmolar (370 mg/ml) lowers the viscosity and has been proven to lower the probability of extravasation <sup>5</sup>
  • +</li></ul>

References changed:

  • 5. Davenport M, Wang C, Bashir M, Neville A, Paulson E. Rate of Contrast Material Extravasations and Allergic-Like Reactions: Effect of Extrinsic Warming of Low-Osmolality Iodinated CT Contrast Material to 37°C. Radiology. 2012;262(2):475-84. <a href="https://doi.org/10.1148/radiol.11111282">doi:10.1148/radiol.11111282</a>

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