Risk Factors for Contrast Media Extravasation in Intravenous Contrast-Enhanced Computed Tomography: An Observational Cohort Study.

RATIONALE AND OBJECTIVES: To identify the risk factors for contrast media (CM) extravasation and provide effective guidance for reducing its incidence. MATERIALS AND METHODS: We observed adult inpatients (n = 38 281) who underwent intravenous contrast-enhanced computed tomography between January 1, 2018, and December 31, 2022. Risk factors for CM extravasation were evaluated using univariate and multivariate logistic regression. RESULTS: Among the 38 281 inpatients who underwent enhanced computed tomography angiography, 3885 received peripherally inserted central venous catheters (PICCs) and 34 396 received peripheral short catheters. In 3885 cases of PICCs, no CM extravasation occurred, but in five cases, ordinary PICCs that are unable to withstand high pressure were mistakenly used; three of those patients experienced catheter rupture, and eventually, all five patients underwent unplanned extubation. Among 34 396 cases of peripheral short catheters, 224 (0.65%) had CM extravasation. Female sex (odds ratio [OR]=1.541, 95% confidence interval [CI]: 1.111-2.137), diabetes (OR=2.265, 95% CI: 1.549-3.314), venous thrombosis (OR=2.157, 95% CI: 1.039-4.478), multi-site angiography (OR=9.757, CI: 6.803-13.994), and injection rate ≥ 3 mL/s (OR=6.073, 95% CI: 4.349-8.481) were independent risk factors for CM extravasation. Due to peripheral vascular protection measures in patients with malignant tumor, there was a low incidence of CM extravasation (OR=0.394, 95% CI: 0.272-0.570). CONCLUSION: Main risk factors for CM extravasation are female, diabetes, venous thrombosis, multi-site angiography, and injection rate ≥ 3 mL/s. However, patients with malignant tumor have a low incidence of CM extravasation. CLINICAL IMPACT: Analysis of these risk factors can help reduce the incidence of CM extravasation.

Management of noncytotoxic extravasation injuries: A focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline.

Extravasation is the leakage of intravenous solutions into surrounding tissues, which can be influenced by drug properties, infusion techniques, and patient-related risk factors. Although peripheral administration of vesicants may increase the risk of extravasation injuries, the time and resources required for central venous catheter placement may delay administration of time-sensitive therapies. Recent literature gathered from the growing use of peripheral vasopressors and hypertonic sodium suggests low risk of harm for initiating these emergent therapies peripherally, which may prevent delays and improve patient outcomes. Physiochemical causes of tissue injury include vasoconstriction, pH-mediated, osmolar-mediated, and cytotoxic mechanisms of extravasation injuries. Acidic agents, such as promethazine, amiodarone, and vancomycin, may cause edema, sloughing, and necrosis secondary to cellular desiccation. Alternatively, basic agents, such as phenytoin and acyclovir, may be more caustic due to deeper tissue penetration of the dissociated hydroxide ions. Osmotically active agents cause cellular damage as a result of osmotic shifts across cellular membranes in addition to agent-specific toxicities, such as calcium-induced vasoconstriction and calcifications or arginine-induced leakage of potassium causing apoptosis. A new category has been proposed to identify absorption-refractory mechanisms of injury in which agents such as propofol and lipids may persist in the extravasated space and cause necrosis or compartment syndrome. Pharmacological antidotes may be useful in select extravasations but requires prompt recognition and frequently complex administration strategies. Historically, intradermal phentolamine has been the preferred agent for vasopressor extravasations, but frequent supply shortages have led to the emergence of terbutaline, a ß2 -agonist, as an acceptable alternative treatment option. For hyperosmolar and pH-related mechanisms of injuries, hyaluronidase is most commonly used to facilitate absorption and dispersion of injected agents. However, extravasation management is largely supportive and requires a protocolized multidisciplinary approach for early detection, treatment, and timely surgical referral when required to minimize adverse events.

Practical Preventive Strategies for Extravasation of Contrast Media During CT: What the Radiology Team Should Do.

RATIONALE AND OBJECTIVES: This study aimed to assess the effectiveness of practical preventive strategies (i.e., venous vulnerability assessment and prevention scan protocol rules) taken by our radiology team (radiology nurses, radiology technicians, radiologists) on reducing extravasation of contrast media (ECM) during CT. MATERIALS AND METHODS: A total of 73,931 patients who underwent contrast-enhanced CT scans between January 2013 and December 2019 were retrospectively included. Venous vulnerability assessment by the radiology team began in 2015, and prevention scan protocol rules for the prevention of ECM were added in 2017. We defined each period as follows: 2013-2014, no prevention (Period A); 2015-2016, early prevention (Period B, venous vulnerability assessment only); and 2017-2019: late prevention (Period C, venous vulnerability assessment with prevention scan protocol rules). The incident reports, radiology reports, and medical records of patients in whom ECM occurred were reviewed. We compared the frequency of ECM during each period. RESULTS: ECM occurred in 0.39% (292/73,931) of the patients. The frequencies of ECM for Periods A, B, and C were 0.62% (121/19,505), 0.43% (89/20,847), and 0.24% (82/33,579), respectively. There were significant differences in the frequencies of ECM among the three periods (Chi-squared test, p < 0.01). CONCLUSION: Implementation of venous vulnerability assessment and prevention scan protocol rules by a radiology team can be a practical and simple solution to reduce the risk of ECM during CT.

Intravenous contrast medium extravasation: systematic review and updated ESUR Contrast Media Safety Committee Guidelines.

NEED FOR A REVIEW: Guidelines for management and prevention of contrast media extravasation have not been updated recently. In view of emerging research and changing working practices, this review aims to inform update on the current guidelines. AREAS COVERED: In this paper, we review the literature pertaining to the pathophysiology, diagnosis, risk factors and treatments of contrast media extravasation. A suggested protocol and guidelines are recommended based upon the available literature. KEY POINTS: • Risk of extravasation is dependent on scanning technique and patient risk factors. • Diagnosis is mostly clinical, and outcomes are mostly favourable. • Referral to surgery should be based on clinical severity rather than extravasated volume.

Does Immobilization Post Injection Reduce Contrast Extravasation in MR Arthrography of the Shoulder?

BACKGROUND: Contrast leakage after arthrography is common. We sought to investigate if immobilization could prevent it. PURPOSE: The purpose of this study was to determine the effects on contrast extravasation and image quality produced by strict immobilization of the shoulder between arthrography puncture and subsequent MR imaging. MATERIAL AND METHODS: Fifty patients underwent shoulder MR arthrography using a standard shoulder puncture in the anteroinferior quadrant. Ten milliliters of contrast mixture of saline, iodinated contrast, and gadolinium contrast was injected by a senior musculoskeletal (MSK) radiologist using a 21G needle. Half of the patients were immediately immobilized using a shoulder sling, and the other half were allowed to move their shoulder and arm freely during the time before MR imaging. MR arthrography was performed with a 3 T system using standard T1 and PD weighted sequences. The MR images were reviewed independently by 2 MSK radiologists and graded for extravasation using a five-point scale (1: none, 2: less than 2 cm, 3: 2-5 cm, 4: 5-10 cm, 5: more than 10 cm) and for image quality using a 5 point scale (1: poor, 5: good). The Pearson correlation was calculated to assess the correlation between leakage and image quality. RESULTS: There was no significant difference in amount of leakage between both groups, and global image quality was found equal in both groups. A negative correlation was found between leakage and quality assessment. CONCLUSION: This study shows that it cannot be avoided by strict shoulder immobilization and that it negatively affects image quality and interpretation.

Possibility of Taking an Offensive Stance in Extravasation Injury: Effects of Fat Injection in Vesicant (Doxorubicin) Induced Skin Necrosis Model in Rats.

INTRODUCTION: Extravasation injuries are one of the most feared complications of intravenous drug administration. The most common drugs associated with extravasation injury include chemotherapy agents and contrast media. Natural course of vesicant extravasation is discomfort, pain, swelling, inflammation, and ultimately skin ulceration. While diligence is the principle approach in prevention, immediate bed-side measures are as important in controlling the extent of tissue damage. Various options, either medical or interventional are next steps in treatment of the condition including antidotes, volume dilution, flushing, suction, hyperbaric oxygen therapy, and surgery. MATERIALS AND METHODS: 12 male Wistar albino rats were divided into two groups; one group received fat injections following subdermal doxorubicin infiltration in their right thighs, while other group received saline injection following subdermal doxorubicin infiltration in their right thighs for dilution. Left thighs of both groups were left untreated following subdermal doxorubicin infiltration. Total area of necrosis, as well as resultant epidermal thicknesses were assessed. Histological analyses were conducted using modified Verhofstad scoring system for comparison. RESULTS: Mean necrotic area was significantly smaller in the fat injection group compared to other groups. Median Verhofstad score was lesser in the fat injection group as well. Median epidermal thickness, on the other hand, was greater in the fat injection group. CONCLUSION: Injection of fat grafts following vesicant extravasation might be beneficial in preventing the progression of tissue damage, if employed early.

Effect of Extrinsic Warming of Low-Osmolality CT Contrast Media (Iohexol 350) on Extravasations and Patient Reaction Rates: A Retrospective Study.

BACKGROUND. Extrinsic warming of iodinated CT contrast media to body temperature reduces viscosity and injection pressures. However, studies examining the effect of extrinsic warming on clinical adverse events are limited in number and provide conflicting results. Therefore, consensus practice recommendations have been sparse. OBJECTIVE. The purpose of this study is to compare rates of extravasation, allergic and allergiclike reactions, and physiologic reactions between iohexol 350 mg I/mL warmed to body temperature (37°C) versus this agent maintained at room temperature. METHODS. This retrospective study compared adult patients who received CT examinations using IV iohexol 350 that had either been warmed to body temperature or maintained at room temperature. At our institution, contrast media had historically been warmed to body temperature before a protocol change unrelated to this investigation. Information on the patient and CT examination was extracted from the electronic medical record. Adverse events, including extravasations, allergic and allergiclike reactions, and physiologic reactions, were compared between groups. RESULTS. A total of 3939 patients received contrast media warmed to body temperature before the protocol change; 3933 patients received contrast media at room temperature after the protocol change. The body temperature group experienced 11 (0.28%; 95% CI, 0.14-0.50%) adverse events, all extravasations; the allergic and allergic-like reaction rate was 0.00% (97.5% CI, 0.00-0.09%). The room temperature group experienced 17 (0.43%; 95% CI, 0.25-0.69%) adverse events: 13 (0.33%; 95% CI, 0.17-0.56%) extravasations and four (0.10%; 95% CI, 0.03-0.26%) allergic and allergiclike reactions. No physiologic reaction occurred in either group. The two groups were not different in terms of overall reaction rate (p = .19), extravasation rate (p = .69), allergic and allergiclike reaction rate (p = .06), or physiologic reaction rate (p > .99). Logistic regression adjusting for patient and CT characteristics (age, sex, conventional CT vs CTA, contrast media volume, injection location) showed no significant association of patient group and adverse reaction rate (odds ratio, 2.19; 95% CI, 0.68-7.00). Multivariable regression modeling showed an excess of 0.27 adverse events per 100 patients within the room temperature group, which is below a 0.6% noninferiority margin. CONCLUSION. The data suggest that maintaining iohexol 350 at room temperature is noninferior to warming the agent to body temperature before injection. CLINICAL IMPACT. The resources involved to prewarm iohexol 350 before injection may not be warranted.

Extravasation (paravasation) of chemotherapy drugs - updated recommendations (2020) for standard care in the Czech Republic from the cooperation of the Supportive Care Group of the Czech Society for Oncology, Czech Society for Hematology, Oncology Section of the Czech Nurses Association and the Society for Ports and Permanent Catheters.

BACKGROUNDS: Extravasation (paravasation) of chemotherapy drugs is a very significant complication. Preventive and therapeutic interventions reduce the risk of the complication or the extent of its consequences. A working group of authors from expert groups prepared recommendations for standard care. PURPOSE: A basic summary of recommended interventions for daily practice, defined on the basis of knowledge from long-term, proven, evidence-based practice or on the consensus opinions of the expert groups representatives. RESULTS: Preventive measures are essential and include early consideration of long-term venous access devices indications, choice of injection site, venous line control before each chemotherapy drug application, and patient education. The intervention in case of extravasation mainly involves the application of antidotes (DMSO, hyaluronidase, dexrazoxane) and the application of dry cold or heat according to the type of cytostatic drug. Subcutaneous corticosteroids, moist heat or cooling and compression are not recommended. CONCLUSION: The recommended procedures contribute to reducing the risk and consequences of extravasation. The range of recommended interventions can be expanded individually depending on individual clinical site policy and needs.

Contrast Reaction Readiness for Your Department or Facility.

Moderate and severe contrast reactions are rare but can be life threatening. Appropriate contrast reaction management is necessary for the best patient outcome. This review summarizes the types and incidences of adverse events to contrast media, treatment algorithms, and equipment needed to treat common contrast reactions, the current status of contrast reaction management training, and preventative strategies to help mitigate adverse contrast events.

Study on preventing adverse events in neonates (SEPREVEN): A stepped-wedge randomised controlled trial to reduce adverse event rates in the NICU.

INTRODUCTION: Adverse events (AE) in care are recognized as a leading cause of mortality and injury in patients. Improving patients' safety is difficult to achieve. Therefore, innovative research strategies are needed to identify errors in subgroups of patients and related severity of outcomes as well as reliably measured efficiency of reproducible strategies to improve safety. This trial aims to evaluate the impact of a combined multiprofessional education program on the rate of AE in neonatal intensive care units (NICUs). METHODS AND ANALYSIS: This is a stepped-wedge cluster randomised controlled trial with 3 clusters each containing 4 units. The study time period will be 20 months. The education program will be implemented within each cluster following a random sequence with a control period, a 4-month transition period and a post-educational intervention period. Eligibility criteria: for clusters: 6 NICUs from Ile-de-France and 6 NICUs from different regions in France; for patients: in-hospital during the study period (November 23, 2015 and November 2, 2017 [inclusion start dates varying by unit]) in one of the 12 NICUs; corrected gestational age ≤42 weeks upon admission; hospitalization period >2 days; and parents informed and not opposed to the use of their newborn's data. A routine occurrence reporting of medical errors and their consequence will take place during the entire study period. The intervention will combine an education to implement a standardized root cause analysis method, creation of bundles (insertion, daily goals, maintenance bundles) to prevent catheter-associated blood-stream infection and a poster to prevent extravasation injuries. OUTCOME: We hypothesize a reduction from 60 (control) to 50 (intervention) AE/1000 patient-days. The primary outcome will be the rate of AE/1000 patient-days in the NICU. TRIAL REGISTRATION NUMBER: NCT02598609, trial registered November 6, 2015. https://clinicaltrials.gov/ct2/show/NCT02598609. ETHICS AND DISSEMINATION: Study approved by the regional ethic committee CPP Ile-de-France III (no 2014-A01751-46). The results will be published in peer-reviewed journals.

Contrast-induced acute kidney injury.

Although major advancements in the field of cardiology have allowed for an increasing number of patients to undergo minimally invasive imaging and interventional procedures, contrast-induced acute kidney injury (CI-AKI) continues to be a dreaded complication among patients receiving intravascular contrast media. CI-AKI is characterized by progressive decline in kidney function within a few days of contrast medium administration. Physiological changes resulting from the direct nephrotoxic effect of contrast media on tubular epithelial cells and release of vasoactive molecules have been implicated in creating a state of increased oxidative stress and subsequent ischemic renal cell injury. Over the last several years, preventive strategies involving intravenous hydration, pharmaceutical agents and renal replacement therapies have resulted in lower rates of CI-AKI. However, due to the evolving paradigm of diagnostic and therapeutic interventions, several unanswered questions remain. This review highlights the epidemiology, pathogenesis and preventive strategies of CI-AKI.

Preventing skin staining: an effective iron infusion protocol.

PURPOSE: To implement a safe and effective intravenous iron infusion protocol to prevent skin staining. DESIGN/METHODOLOGY/APPROACH: Mixed methods approach was utilised including education, auditing, self-reported survey, patient information leaflet and patient feedback. In total 25 healthcare professionals completed the survey and 15 patients provided feedback. FINDINGS: No skin staining or severe adverse reactions were observed over eight weeks. Audit results found 53 per cent of staff were compliant with the recommended IV iron infusion protocol and 46 per cent informed patients of skin staining risk. Self-report surveys indicated 92 per cent flushed the cannula with sodium chloride before starting the infusion, 88 per cent flushed the cannula after the infusion and 76 per cent informed patients of skin staining risk. Patient feedback was largely positive and constructive. RESEARCH LIMITATIONS: Limitations include self-reported bias, short audit time interval, missing data and discrepancy between audit and survey results. ORIGINALITY/VALUE: This quality improvement project was developed following two skin staining incidences at our maternity hospital. Although rare, skin staining after intravenous iron infusion is potentially permanent and may be distressing for some patients. Intravenous iron is considered safe and effective to treat anaemia during pregnancy and is often prescribed for this patient cohort. To avoid medicolegal action and patient dissatisfaction, it is essential that patients are informed of potential skin staining and an evidence-based administration protocol is utilised.

Prevención y tratamiento de la extravasación de quimioterapia intravenosa / Prevention and Treatment of Extravasation of Intravenous Chemotherapy

RESUMEN Introducción: La extravasación endovenosa de citostáticos es una grave complicación del tratamiento en el paciente con cáncer, que puede provocar graves daños tisulares. Objetivo: Sistematizar las medidas de prevención y tratamiento a tomar por los profesionales de enfermería en la extravasación de quimioterapia intravenosa. Métodos: Revisión bibliográfica sistemática con análisis de contenido de documentos originales y de revisión publicados en español e inglés desde 2009 a 2016, con las siguientes palabras clave: "extravasación", "quimioterapia", "medidas de prevención", "tratamiento de extravasación" en SciELO. Se identificaron y revisaron artículos que fueron útiles para el desarrollo de la revisión, así como monografías de varias revistas y tesis doctorales actualizadas que permitieron el análisis histórico lógico de los criterios que sustentan medidas de prevención y tratamiento en la extravasación de quimioterapia intravenosa. Conclusiones: La prevención de esta complicación ha demostrado ser la mejor medida para evitar el daño a los tejidos, sin embrago existen tratamientos alternativos que el personal de enfermería debe conocer y aplicar con rapidez y eficiencia(AU)

ABSTRACT Introduction: Intravenous cytostatic extravasation is a serious complication of treatment in cancer patients, which can cause serious tissue damage. Objective: To systematize the prevention and treatment measures to be taken by nursing professionals in case of extravasation of intravenous chemotherapy. Methods: Systematic bibliographic review with content analysis of original and review documents published in Spanish and English in SciELO from 2009 to 2016, with the following keywords: extravasación [extravasation], quimioterapia [chemotherapy], medidas de prevención[prevention measures], tratamiento de extravasación[treatment of extravasation]. Articles that were useful for the development of the review were identified and consulted, as well as monographs of several updated journals and doctoral theses, which allowed the logical-historical analysis of the criteria that support prevention and treatment measures in the extravasation of intravenous chemotherapy. Conclusions: The prevention of this complication has proven to be the best measure to avoid tissue damage; however, there are alternative treatments that nurses should know and apply quickly and efficiently(AU)

Percutaneous Vertebral Augmentation for Osteoporotic Vertebral Compression Fracture in the Midthoracic Vertebrae (T5-8): A Retrospective Study of 101 Patients with 111 Fractured Segments.

OBJECTIVE: Data reporting percutaneous vertebroplasty (PVP) or percutaneous balloon kyphoplasty (PKP) application to the midthoracic vertebrae remain limited. This study aimed to summarize our experiences and explore the efficacy and safety of PVP or PKP in dealing with osteoporotic vertebral compression fracture (OVCF) in the midthoracic vertebrae. METHODS: Patients receiving PVP or PKP for midthoracic OVCF in our institution from January 2015 to January 2018 were retrospectively enrolled. All patients were grouped according to cement augmentation procedure types, surgical approaches, and puncture routes. All patients underwent a postoperative follow-up of 2-36 months. Visual analog scale (VAS) and ECOG Scale of Performance Status scores were evaluated pre- and postoperatively. Cement distribution and rate of cement leakage were assessed by radiographs. Associations of these variables and clinical scores and radiographic indices were analyzed. RESULTS: A total of 101 consecutive patients with 111 fractured centrums were enrolled. Both VAS and ECOG Scale of Performance Status scores of all patients decreased significantly after the operation, and progressively decreased at the final follow-up. The cement distribution of the bipedicular group was significantly better than the unipedicular group, but the total leakage rate of the former (71.7%) was significantly higher than the latter (43.1%). The rate of epidural cement leakage in the PKP group (5.4%) was significantly lower than that of the PVP group (20.3%), whereas the left puncture group (28.6%) was significantly higher than that of the right puncture group (2.7%). CONCLUSIONS: PKP and a bipedicular approach can help improve cement distribution and reduce the epidural cement leakage rate and therefore should be preferred over PVP or a unipedicular approach in OVCF of the midthoracic vertebrae.

When in Doubt, Pull the Catheter Out: Implementation of an Evidence-Based Protocol in the Prevention and Management of Peripheral Intravenous Infiltration/Extravasation in Neonates.

The vast majority of infants in the NICU receive peripheral intravenous (PIV) therapy for administration of fluids, nutrition, medications, and blood products. The potential complications of infiltration and extravasation are common in this population. Consequences of inf.ltration and extravasation may be prevented or mitigated by early detection and prompt treatment. In addition, innovative therapies for wound care are constantly evolving. In order to improve outcomes, a practice guideline for intravenous (IV) infiltration prevention, management, and treatment is presented based on literature review and consultation with wound care experts. The guideline includes preventive measures, standardized IV assessment, staging, an algorithm outlining injury, and wound care recommendations.