1. Dallas, TX November 2–4, 2012 Reducing Contrast Extravasation Linda McDonald, MSN, RN, CRN Radiology Advanced Practice Nurse Children’s Hospital of Pittsburgh of UPMC

2. Dallas, TX November 2–4, 2012 Objectives Discuss how contrast delivery is different from most other medications and how this impacts extravasation List three actions to reduce extravasation potential during contrast delivery

3. Dallas, TX November 2–4, 2012 Extravasation of 70ml of Iodinated Contrast Media

4. Dallas, TX November 2–4, 2012 This took 17.5 seconds to happen

5. Dallas, TX November 2–4, 2012 What is an extravasation ? “the inadvertent infiltration of vesicant solution or medication into surrounding tissue” 1 Vesicant – “an agent capable of causing blistering, tissue sloughing, or necrosis when it escapes from the intended vascular pathway into surrounding tissues” 1

6. Dallas, TX November 2–4, 2012 What Does The Patient Feel? Most feel a sensation of swelling or tightness, Wang,et al reported 79% experienced this 5 Most also feel stinging or burning pain at the site, Wang, et al reported 24% experienced this 5 Some feel nothing at all 2, Wang, et al reported 8% experienced no symptoms 5

7. Dallas, TX November 2–4, 2012 Incidence of Contrast Extravasation American College of Radiology (ACR) reports a 0.1% to 0.9% rate of extravasation from power injection of contrast media for a CT scan Equates to 1/1000 to 1/106 patients Frequency not related to injection flow rate

8. Dallas, TX November 2–4, 2012 What is IV contrast ? diagnostic material that alters x-ray absorption by body tissues or organs can discriminate between disease and normal tissue Many diseases would go undetected if contrast media was not used 3

9. Dallas, TX November 2–4, 2012 Where is it used ? Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Positron Emitting Imaging with CT (PET/CT) Fluoroscopy Angiography

10. Dallas, TX November 2–4, 2012 Types of IV Contrast Iodine-based contrast – used in CT, Angiography, Fluoroscopy - Ionic – 1 st generation - Non-ionic – 2 nd generation - Iso-osmolar – 3 rd generation Gadolinium-based contrast – used in MRI

11. Dallas, TX November 2–4, 2012 Contrast Characteristics That Are Problematic Osmolality Viscosity pH

12. Dallas, TX November 2–4, 2012 Osmolality of Contrast Media Osmolality – “number of milliosmoles per kilogram of solvent”, measure of the total number of particles (solutes) in a solution 1 Normal serum osmolality is 280-295 mOsm/kg H 2 O IV Contrast medias range from 290 - 1970 mOsm/kg H 2 O 2

13. Dallas, TX November 2–4, 2012 Viscosity of Contrast Media describes a fluid's internal resistance to flow - a measure of fluid friction 4 water is “thin” with low viscosity honey is “thick” with high viscosity Range from 2 - 26.6 cP

14. Dallas, TX November 2–4, 2012 pH of Contrast Media The acidity or alkalinity of a substance 1 Blood has a pH of 7.35-7.45 Range from 5.5 – 8.0

15. Dallas, TX November 2–4, 2012 Comparison of Iodinated IV Contrasts Ionic – HOCM (high osmolar contrast media) - osmolality 1000-1551 mOsm/kgH2O - viscosity 6-16.4 cps at 25°C, 4-10.5 cps at 37°C Non-ionic – LOCM (low osmolar contrast media) - osmolality 744-874 mOsm/kgH 2 O - viscosity 14.3-22 cps at 25°C, 9-10.4 cps at 37°C Iso-osmolar – IOCM - osmolality 290-769 mOsm/kgH2O - viscosity 20.9-26.6 cps at 25°C, 9.4-26.6 cps at 37°C

16. Dallas, TX November 2–4, 2012 Comparison of Gadolinium Contrast Media Gadolinium -osmolality 688 - 1970 mOsm/kgH2O -viscosity 2 - 9.2 cps at 25°C 1.4 - 5.3cps at 37°C

17. Dallas, TX November 2–4, 2012 How is IV Contrast Injected ? Hand injected by a syringe Mechanically injected by a power injector

18. Dallas, TX November 2–4, 2012 Why Use Power Injectors ? Best enhancement seen in 15 – 120 seconds after injection 7 Small volumes can be quickly injected by hand Larger volumes can not be injected fast enough by hand Today there are CT scanners that can scan a whole body in 5 seconds

19. Dallas, TX November 2–4, 2012 How Fast Does it Inject ? Rates ranging from 1-10ml per second Adult for CT of abdomen and pelvis with contrast commonly receives 60ml of contrast at 4ml per second 60ml is injected in 15 seconds

20. Dallas, TX November 2–4, 2012 How Much Pressure is Used ? Most injectors are set at a default of a maximum pressure setting of 300-325 psi Injectors only exert the psi necessary to deliver the contrast at the rate programmed

21. Dallas, TX November 2–4, 2012 What Steps Are Taken To Prevent Extravasation ? Inspect the site Verify blood return Verify ability to flush easily with NSS Verify patient has no discomfort with NSS flush Verify that the catheter and accessory products are power injectable Verify flow rate is appropriate for the catheter size

22. Dallas, TX November 2–4, 2012 What Steps Are Taken to Detect Extravasation ? Patient instructions – get cooperation to immediately tell RT if any pain or sensation of swelling Palpation of site during first 15 seconds of injection, then RT exits scan room Maintain communication with the patient via intercom and/or video monitor

23. Dallas, TX November 2–4, 2012 Equipment That May Help Reduce Extravasation Extravasation detectors – sensors placed on skin - designed to prevent moderate to severe contrast extravasations Dual head injectors that inject saline prior to the contrast

24. Dallas, TX November 2–4, 2012 ACR Recommendations ACR recommends use of the antecubital or forearm vein – if smaller hand or wrist vein is used then injection rate should be decreased to 1.5ml/sec 2 Metal needles should be avoided and flexible plastic cannula used 2

25. Dallas, TX November 2–4, 2012 What IV Access Device is Used? Central Venous Access Devices –Power injectable catheters and ports –Preferable because they are located in larger central veins and power injection requires less psi to deliver the desired rate Peripheral Venous Catheters –Catheters must be power injectable –Gauge of catheter must be large enough to accommodate the required rate of flow –Accessory devices must be power injectable

26. Dallas, TX November 2–4, 2012 Short Peripheral IV Devices Infusion Nursing Standards of Practice have stated these catheters are not appropriate for “infusates with osmolality >600mOsm/L.” 1 Risk – Benefit assessment of the patient to determine appropriateness of central venous access vs. short peripheral IV catheter access

27. Dallas, TX November 2–4, 2012 What Patients Are Most At Risk of Extravasation Those unable to communicate Abnormal circulation in the limb to be injected Altered circulation such as in PVD, diabetic vascular disease, Reynaud’s Disease Venous thrombosis or insufficiency

28. Dallas, TX November 2–4, 2012 What Patients Are Most At Risk of Extravasation cont. Multiple punctures in to the same vein Prior radiation or extensive surgery in the limb to be injected Peripheral IV catheters that have been in place more than 24 hours Catheters in sites such as the hand, wrist, foot or ankle are at higher risk

29. Dallas, TX November 2–4, 2012 When Extravasation Does Occur What Happens ? Toxic to the surrounding tissues especially the skin Acute local inflammatory response that make peak in 24-48 hours Most will resolve without further problems Rare occurrence of severe symptoms – most common is Compartment Syndrome

30. Dallas, TX November 2–4, 2012 How Do We Reduce The Incidence of Contrast Extravasations? Collaboration of all disciplines involved in the patient’s vascular access –ED and inpatient physicians & nurses –IV Team –Radiology –Oncology –Pharmacy

31. Dallas, TX November 2–4, 2012 Case Study Contrast extravasation rate was 0.6% Volume of contrast extravasated was commonly over 50ml 75% of contrast extravasations occurred in pre-existing IV on ED or inpatients Non-power injectable accessory devices were in use

32. Dallas, TX November 2–4, 2012 Actions Education on contrast media, vein selection, assessment of venous access, assessment for use of power injectable devices, & treatment of extravasations for radiology RNs and RTs Education expanded to include radiologists and radiology residents Each extravasation was investigated & patient was followed until resolved

33. Dallas, TX November 2–4, 2012 Results Slightly improved outcomes –Extravasation rate slightly decreased –Volume of contrast extravasated was lower –Use of only power injectable accessory devices became the standard –Still saw inpatients and ED patients experiencing most of the extravasations

34. Dallas, TX November 2–4, 2012 What Next ? Hospital Extravasation Task Force was created – was a subcommittee of the Patient Safety Committee –Radiology –IV Team –Oncology –Patient Safety –Emergency Department –Inpatient Nursing –Plastic Surgery –Pharmacy

35. Dallas, TX November 2–4, 2012 What Was Found ? Discovered that many pre-hospital IV catheters were involved in extravasation Found that education for nurses, paramedics and technologists varied greatly Staff had no involvement with IV product selection Extravasation treatment was inconsistent

36. Dallas, TX November 2–4, 2012 Next Steps Standardized mandatory IV education housewide for all RNs and all IV starters/injectors Changed hospital policy requiring IV catheter removal within 24 hours for those started outside the hospital Developed hospital extravasation policy that defined vesicants and treatment, standardized documentation of extravs

37. Dallas, TX November 2–4, 2012 Collaborations ED and Radiology worked together –ED RN or Paramedic would immediately start a new IV with power injectable accessories on all trauma and stroke patients, this IV was indicated for use to inject IV contrast –Trauma Team changed brand of triple lumen catheter to a power injectable one

38. Dallas, TX November 2–4, 2012 Collaborations IV Team and Radiology worked together –Education done for IV Team RNs about contrast media and need for certain gauge catheters for certain studies –PICC nurses included possible need for CT and MRI contrast injection in their decision algorithm for catheter selection which resulted in more power injectable PICCs inserted

39. Dallas, TX November 2–4, 2012 Collaborations Oncology and Radiology worked together –Power Ports were only to be accessed with a power injectable huber needle –Education for the oncology staff regarding contrast media injection focusing on assessment of solutions that have been administered through that catheter & possible need of new site prior to CT –Hospital port now power injectable

40. Dallas, TX November 2–4, 2012 Results

41. Dallas, TX November 2–4, 2012 Lessons Learned Collaboration is the key to successfully reducing contrast extravasations Communication between all disciplines involved in the patient’s care is imperative We can improve patient safety and satisfaction when we work together

42. Dallas, TX November 2–4, 2012 References 1.Infusion Nurse Society. (2011, January/February). Infusion Nursing Standards of Practice. Journal of Infusion Nursing, ppS5-108. 2.American College of Radiology (2012). Retrieved August 30, 2012 from ACR Manual on Contrast Media Version 8. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/Co ntrast%20Manual/FullManual.pdf. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/Co ntrast%20Manual/FullManual.pdf 3.Gross, K., & Costa, N. (2008). Core Curriculum for Radiologic and Imaging Nursing, 2 nd Edition (pp1-83). Pensacola: American Radiological Nurses Association. 4.MEDRAD XDS® Extravasation Detector. (2012), Bayer HealthCare Radiology & Interventional. Retrieved August 30, 2012 from http://www.medrad.com/en- us/info/products/Pages/XDS-details.aspx. http://www.medrad.com/en- us/info/products/Pages/XDS-details.aspx 5.Wang, C., Cohan, R., Ellis, J., Adusumilli, S., & Dunnick, N.(2007, April). Frequency, Management, and Outcome of Extravasation of Nonionic Iodinated Contrast Medium in 69,657 Intravenous Injections. Radiology, pp 80-87.

43. Dallas, TX November 2–4, 2012 Questions ? linda.mcdonald2@chp.edu Thank you