When Contrast Extravasates: What Do I Do?

Richard H. Cohan, M.D. and James H. Ellis, M.D.

(www.indyrad.iupui.edu)

 

Plaintiff:          A 36-year-old female with vague abdominal pain referred for an

abdominal CT examination. During the contrast injection, approximately 150 ml of nonionic contrast material extravasated into the left antecubital fossa.

 

Defendant:     A 47-year-old neurotic radiologist who just happened to be assigned to CT

that day. The radiologist did not start the IV line (a technologist did), but was called to see the patient. He applied warm compresses and called the patients referring physician before sending the patient home with instructions to return should her swelling worsen. The radiologist never heard anything further.

 

…for two years until the complaint arrived…

 

Allegations by the defendant:

 

1.      The patient was not informed of the possibility of extravasation prior to   injection and to possible adverse outcomes from an extravasation.

2.      When the IV line was being inserted, the patient told the technologist that she  

      was having a lot of pain and demanded that they remove the angiocatheter.   

      The technologists did not respond to her, but proceeded anyway.

3.      Once the contrast material was injected, that patient screamed in pain for over

two minutes, during which time she was ignored by the technologists, who assured her that everything was fine. Almost all of the contrast material had been injected before the technologist removed the needle and called a doctor.

4.      No physician ever came to evaluate the patient and she was sent home with no

instructions.

5.      She went to a local emergency room later that evening with increased

swelling and absent pulses in her extremity. Emergency surgery was performed.

6.      The patient has had constant pain since that time. She has had two operations

for ulnar nerve decompression and she has been in physical therapy for many months without improvement.

 

Issues to be discussed:

 

1.      Should the radiologist have done anything differently?

2.      Could the episode have been prevented? What can be done to minimize that  

risk of patient discomfort and injury?

3.      What is the typical outcome in patients with large volume extravasations?

4.      Is the radiologist liable?

5.      Could the litigation have been avoided? What can be done to minimize the

risk of litigation? Some possible outcomes of litigation will be discussed.

 

Facts about contrast media extravasation

 

Frequency: The number of reported contrast media extravasations during CY has increased markedly over the past few years as high-rate dynamic bolus techniques with automated injector have become widely used. Currently, extravasations are detected in 0.25-0.9% of all patients referred for contrast-enhanced CT [1-3]. While the frequency of severe injuries after contrast extravasation during CT is unknown, such injuries are extremely uncommon. In three series including over 30,000 patients, all 135 extravasations (some involving ionic contrast material) resolved without long-term sequelae [1-3].

 

Injuries after extravasation of ionic agents: Ionic contrast material has much greater skin and subcutaneous toxicity than nonionic contrast material. Skin ulceration and necrosis are occasionally encountered. As with any large volume extravasation, compartment syndromes can occur. Some patients develop chronic scarring and long-term pain. Reconstructive surgery may be required. Reports of adverse sequelae have appeared in the radiologic and plastic surgery literature. [4].

 

Injuries after extravasation of nonionic agents: There have only been three published reports of injuries produced by extravasated nonionic contrast media. In one, a 30 cm 2 area of ulceration developed in a comatose patient after extravasation of 150 ml of iohexol from an upper extremity injection site [5]. The extravasation occurred while an automatic blood pressure cuff (higher on the arm) was inflated. Only topical treatment was required in this patient. In the second instance, a compartment syndrome resulted form injection of over 180 ml of iohexol- 350 agent into a patient’s forearm [6]. Emergency fasciotomy was performed. The third case involved a 60 ml extravasation of iohexol- 320 into the dorsum of the hand during a CT which produced swelling and blistering [7]. A compartment syndrome also developed and emergency fasciotomy was required. Although each reaction was significant, in no case was debridement or reconstructive surgery required.

 

There have been anecdotal unpublished reports of compartment syndromes resulting from extravasation of small volumes of nonionic contrast material (10-20 ml), as well as of chronic pain after a large volume extravasation of nonionic contrast material (RHC, personal communications).

 

Risk factors for extravasations: Some patients are more likely to develop extravasations. This includes patients at extremes of age or who are unconscious [4]. These individuals are less likely to complain of injection site pain. Extravasations are also more probable in patients injected through small peripheral veins, after injection through metal needles (such as butterflies) rather than plastic cannulae, when tourniquets are not released, such as may be the case during lower extremity venography, and after injection through an indwelling intravenous line [4]. Multiple attempts to establish venous access through the same vein can also be a problem. Contrast material that is properly instilled through a peripheral vein may occasionally leak out of a defect just created more centrally [4].

 

Risk factors for severe extravasation injuries: Patients with impaired circulation, such as those with sever atherosclerosis, diabetes mellitus, connective tissue disease, prior radiation to an injection site, or central or peripheral venous thrombosis, are at increased risk for a severe complication from an extravasation [4]. Severe extravasation injuries are also more common in the elderly or very young, possibly because extravasations are more frequent in these patients [4]. Larger volume extravasations are more likely to cause tissue damage [4]. Significant morbidity from extravasation is also more likely to result when injections are performed into the dorsum of the hand, foot, or ankle, rather than the antecubital fossa [4].

 

Recommendations: We recommend that all radiologists who use radiographic contrast material have a policy in place to deal with extravasation injuries. This policy should take into consideration the reduced toxicity of nonionic contrast material and the likelihood that most extravasation injuries heal without the need for surgery. The policy should be developed in consultation with whichever physicians would have to treat a patient with a major extravasation injury. The policy should include provisions for recording the severity of an extravasation injury and for close patient monitoring and follow-up. The policy should also be designed to help minimize the duration of patient discomfort. Patient should not be sent home without instructions about what to do if their symptoms do not resolve. They should instead feel confident that this complication is being properly handled. Our policy is reviewed in detail elsewhere [4], but is summarized here.

 

If an extravasation occurs, the affected extremity is elevated above the level of the heart. Ice packs are applied. The patient is monitored in the radiology department for two to four hours. The extravasation site is periodically inspected for increased swelling or pain, altered tissue sensation or perfusion, or skin ulceration or blister, The Plastic Surgery service is consulted immediately if a patient develops these signs or symptoms. In addition, Plastic Surgery consultation is also requested for any extravasated volume estimated to exceed the arbitrarily chosen threshold volumes of 30 ml of conventional ionic and 100 ml of nonionic contrast media. The radiologist should notify a referring physician whenever the volume of extravasation contrast material is > 5 ml. 

 

If patient symptoms are mild and do not worsen over time, the patient can be discharged after two to four hours. This can be done even if large volume extravasations have occurred (after Plastic Surgery has been consulted). The patient is given a telephone number to call if his or her status changes. A physician or nurse also phones the patient daily until signs and symptoms have completely disappeared. During these telephone calls the patient is asked whether his or her pain is increasing, and whether there is any blistering, ulceration, color, temperature, or consistency change at the injured area. If the patient answers affirmatively to any of these questions, he or she may be asked to return to the hospital for further evaluation. Documentation of this entire process is required. A contrast extravasation report form is complete by the physician, nurse, and/or technologist who witnesses the extravasation. The information collected during follow-up telephone calls is recorded on an additional sheet of paper (which also lists the questions that the calling nurse or radiologist is expected to ask). This sheet of paper is then added to the patient’s medical record.

 

Extravasation of MR Contrast agents: Animal studies have demonstrated that gadopentetate dimeglumine, the most widely used MR contrast agent, is capable of producing skin ulceration and necrosis [8,9], although it is better tolerated than conventional ionic radiographic contrast media. Since lower volumes of MR agents (in comparison with iodinated contrast media) are usually injected, serous injuries resulting from extravascular injections of gadopentetate should be much less frequent than injuries after extravasation of iodinated radiographic contrast media.

 

References:

1.      Bullard MA, Cohan RH, Ellis JH, Jan SH, Francis IR, Dunnick NR.  

      Extravasation of intravenous contrast material: incidence, management,   

      outcome. Academic Radiol 1997; 4:711-718.

2.      Federle MP, Chang PJ, Confer S, Ozgun B. Frequency and effects of extravasation of ionic and nonionic CT contrast media during rapid bolus injection. Radiology 1998; 206:637-640.

3.      Jacobs JE, Bimbaum BA, Langlotz CP. Contrast media reactions and extravasation: relationship to intravenous injection rates. Radiology 1998; 209: 411-416.

4.      Cohan RH, Ellis JH, Garner WM. Extravasation of radiographic contrast material: recognition, prevention, and treatment. Radiology 1996; 200: 593-604.

5.       Pond GD, Dorr RT, McAleese KA. Skin ulceration from extravasation of low-osmolality contrast medium: a complication of automation. AJR 1992; 158: 915-916.

6.      Memolo M, Dyer R, Zagoria RJ. Extravasation injury with nonionic contrast material. AJR 1993; 160: 203.

7.      Young RA. Injury due to extravasation of nonionic contrast material (letter). AJR 1994; 162: 1499.

8.      McAlister WH, McAlister VI, Kissane JM. The effect of GD-dimeglumine on subcutaneous tissues; a study with rats. AJNR 1990; 11:325-327.

9.      Cohan RH, Leder RA, Herzberg AJ, Hedlund LW, Wheeler CT, Beam CA, Nadel SN, Dunnick NR. Extravascular toxicity of two magnetic resonance contrast agents: preliminary experience in the rat. Invest Radiol 1991; 26: 224-226.