Contrast agents

Explain why we need contrast agents

On a radiograph when two adjacent structures have similar density, and similar atomic number then
there is no contrast between the two meaning that they are difficult to distinguish on the radiograph.

Soft tissues and fluids have the same radiopacity – so blood in the heart, spleen, liver or urine in the
bladder or kidneys cannot be visualised.

We use contrast agents to increase radio-opacity against the surrounding soft tissue structures. E.g
we need to artificially increase the density of the urine and also the atomic number in order to increase
visualisation.

Explain the terms positive and negative contrast agents

Positive contrast agents have a high atomic number and high density and appear more radio-opaque
than surrounding tissue. Examples are Barium sulphate and Iodine

Negative contrast agents are gases that have low density and thus appear radiolucent on a radiograph.
Examples are Air and Carbon dioxide

Outline the essential properties of a positive contrast agent

 They must have significantly different density, for the organ tissue to be visualised against
surrounding tissues
 They mustn’t have any toxic effects we don’t want the contrast to harm the patient
 Must be acceptable to the patient. So some contrast agents can be administered orally,
therefore they need to be palatable and tolerable.
 The contrast should be cost effective. We use contrast agents a lot in radiology examinations
therefore we must ensure that it is not too expensive and we are getting value for money.
 The contrast needs to be stable. So when it enters the body the chemical structure of the
contrast agent remains the same, as soon as the chemical structure changes in the body that
is when the patient will experience adverse effects

Discuss the use of barium sulphate as a contrast agent

 Barium sulphate is a white crystalline compound. It has an atomic number of 56. Making it
appear radio-opaque on images so has good opacification
 Homogenous density of 4500kg/m3 so the appearance of it isn’t patchy.
 Barium sulphate is used for radiology examinations of the upper and lower GI tract (so
oesophagus, stomach, small intestine and large intestine)
 Barium sulphate when mixed with water doesn’t dissolve, therefore it is a suspension.
 One of the main features of using barium sulphate for radiographic contrast agent is its
ability to coat the GI tract, so it gives a thin layer and coats the mucosal lining

Barium sulphate products on the market.

1)EZ-HD is a powder and you add water and shake it. Baritop is suspension already with water inside
the can. It’s used for the oesophagus and stomach so suitable for an examination such as a barium
swallow or barium meal

2)Polybar is for the large bowel and the powder comes in a bag, you add water and mix thoroughly.
This is then administered into the patient via the rectum in a barium enema examination.
IF the label says 85% w/w – this means that there is 85g of barium in 100g of product. 250% w/v
there are 250g of barium sulphate in a volume of 100mL of suspension. Basically the higher the w/v
the more barium sulphate is inside and the denser it is.

Why we do different barium procedures

1) Barium swallow - To see the transit of the barium from the mouth into the stomach.
2) barium Meal allowing us to visualise the transit of barium from the stomach throughout the
small intestine. The coating allows us to visualise the mucosal patterns. I
3) Barium enema, so barium has been introduced rectally. This is a double contrast
examination, so a positive and a negative contrast agent are used together to improve
visualisation of the bowel.

Discuss the use of iodine as a contrast agent

 Iodinated contrast agents contain iodine and they are water soluble – unlike barium
sulphate.
 Iodine has a high atomic number and high density which means it is radiopaque on a
radiograph.
 Iodine based contrast agents can be administered into the body via a number of routes, they
can be injected into the vascular system into both arteries and veins, it can also be
introduced into the spinal canal. It can also be orally administered.
 Iodinated contrast can be used to visualise a number of body systems such as the urinary
tract, the biliary tract and the GI tract in cases whereby barium sulphate is contraindicated.
It can be used in the cardiovascular system to visualise blood vessels throughout the body It
can also be used to visualise the spinal canal and brain

Method of excretion

The contrast agent is introduced into the body cavity, it is quickly absorbed by the blood as it is
water soluble. As the contrast agent is useless to the body it is quickly transported to the kidneys
to be excreted in the urine

Types of Iodinated contrast agents

Define the term osmolality

Osmolality refers to the number of dissolved particles in a particular liquid. Osmolality is measured
in mOsm/kg milliosmoles per kg. The higher the osmolality the more particles are dissolved in it –
and therefore the more concentrated it is.

Why is osmolality important

Osmolality of Iodinated contrasts

 Ionic – 1000-2000 mOsm/kg HOCM High osmolar contrast agent

 Non Ionic Monomer - 600 mOsm/kg LOCM Low osmolar contrast agent
 Non ionic Dimer – 290 – 300 mOsm/kg IOCM Isomolar contrast agent same as body fluid

Blood and cerebrospinal fluid has an osmolality of 295. This means in the body inside the cell the
osmolality is 295mOsm/kg.

We inject an ionic contrast agent which has an osmolality of 1500mOsm/kg. The concentration
outside of the cell increases to 1500mOsm/kg.

The body has to address this imbalance of osmolality. The body wants all fluids to be the same
osmolality so in order to compensate water moves out of the cell in order to try and reduce the
concentration and lower the osmolality outside of the cell.

The movement of water out of the cell causes the cell to become dehydrated and it is this reason
why we see patients having adverse reactions to contrast media. The higher the osmolality of the
contrast agent, the more chances the patient will experience adverse effects.

Thus the best contrast media for reducing chances of reaction is the non-ionic dimer as its osmolality
is the same as blood.

Effects on the cell

 Hypertonic – When the concentration outside of the cell has higher osmolality than inside
the cell. Causing water to move outside the cell, making the cell dehydrated.
 Isotonic – When the concentration inside and out are balanced
 Hypotonic – When the concentration outside of the cell has a lower osmolality than inside
the cell. Causing more water to move into the cell leading to the cell to swell and rupture.
Define the term viscosity

The viscosity of a liquid assessed by measuring its rate of flow through a standard capillary tube. The
Higher viscosity – longer the rate of flow.

Viscosity dependant on

 Concentration/strength - referring to the concentration of iodine in milligrams per millilitre.

So the more iodine or the stronger the strength of iodine in the contrast the more viscose it
becomes. Higher viscosity indicates increased rate of flow i.e. increased longer injection
time.
 Size of the molecules -
 Temperature. The higher the temperature the less viscose the contrast media becomes

Viscosity affects rate at which contrast can be injected. Different contrast agents have different
viscosities

Why is it important

The implication for practice is that we introduce iodine based contrast agents into our patients via a
cannula. So we need to consider how easy it is to inject. Contrast media with higher viscosity will be
much harder to inject and will take much longer to inject.

Discuss the different types of contrast agents

Ionic contrast media HOCM 1000-2000 mOsm/per kg HOCM

 High Osmolality (1000 – 2000mOsm/kg)

 Low viscosity
 COO and Na split apart in water to form two particles
 No longer used as an intravascular contrast agent
 Brand names; Gastrografin, hypaque urografin
 Contraindicated if there is a risk patient will aspirate

Non Ionic contrast media LOCM

 Low osmolality (600mOsm/kg)

 Low viscosity
 Widely used clinically
 Relatively inexpensive (£4/bottle)
 Can be used intravascularly & intrathecally
 Brand names; Omnipaque, Niopam, Ultravist, Optiray

Non ionic dimer contrast media IOCM

 Iso-osmolar 290 – 300mOsm/kg

 Higher viscosity
 Widely used for intravascular applications
 Lower risk of adverse reaction
 Slightly more expensive £7/bottle
 Brand Examples; Visipaque, Isovist
Describe how different contrast agents are prescribed

 Patient group directive (PGD) for scan protocols

 Written record by Radiologists, signed, dated and scanned into RIS
 Prescribed by Radiologist during electronic vetting process
 Formal prescription on a drug chart
 Patient should be fully aware of the procedure and agrees to it
 Informed consent

Describe the risk assessment undertaken with a patient prior to administering RCA

To reduce the patient's chances of experiencing an adverse reaction, a risk assessment needs to be
undertaken to highlight individuals who may be at increased risk.

 Previous contrast reaction

 Asthma
 Renal problems
 Diabetes
 Metformin therapy

Explain the precautions that should be considered for patients who present with specific risks

 Previous contrast reaction - Establish the nature of the reaction e.g. hives, breathing, etc
What contrast agent was used? Check RIS to see if possible
 Asthma – Asthma sufferers may go into bronchospasm. Establish if the asthma is well
controlled.

Actions:

 Re-examine need for contrast, alternative examination?

 Use a different compound to previously or IOCM
 Closely monitor the patient
 Leave the cannula in situ & observe patient for 30mins following procedure
 Have emergency drugs and equipment readily available

 Renal problems (Renal transplant, over 75) - Renal impairment – RCA nephrotoxic to kidney
Contrast induced acute kidney injury (CI-AKI) 25% increase in serum creatinine in 2-3 days

Symptoms; fatigue, poor appetite, swollen legs/ankles

Action

 Check creatinine and estimated glomerular filtration rate (eGFR)

 Low eGFR and high Creatinine = renal impairment
 Alternative examination?
 Risk vs benefit ratio
 Minimise dosage – non ionic dimer
 Hydration regime post examination
  Diabetes - Type 1 Insulin dependant  Type 2 Metformin therapy

Actions

 Type 1 – as per renal impairment (previous slide)  Type 2 – creatinine and eGFR normal
continue metformin
 High creatinine and low eGFR stop metformin for 48 hours following examination
 Minimal dosage of contrast agent and Hydration therapy post examination

Identify adverse reactions that may occur and outline the action that should be undertaken

Adverse Reactions can be categorised as:

 Minor – nausea, vomiting, rash, pain, facial flushing

 Actions – Observation, reassurance, Provide tissues

 Major – urticaria, facial oedema, bronchospasm, hypotension

 Actions – Anti-histamines, oxygen therapy, metered dose inhaler and adrenaline - narrows
blood vessels and opens airways in the lungs in an aim to increase blood pressure

 Severe – shock, convulsions, respiratory and cardiac arrest

 Action- diazepam, intubation, ventilation, cardio-pulmonary action and cardiac fibrillation

Describe the medico-legal consideratons associated with utilising RCA

 Adverse reactions must always be accurately documented

 Contrast Agent;
 Dose e.g. 50ml/100ml
 Concentration e.g. 140, 270, 300
 Type e.g. Omnipaque, niopam, visipaque
 Method of introduction e.g. right antecubital fossa
 Expiry date
 Batch Number
 Type of reaction and action taken
 Observations undertaken
 Complete an incident form

Contrast extravasion - Contrast agent leaks into the tissue around the vein where the cannula was
placed

Risk factors; Elderly, Site of venous access, HOCM, Injector pumps (CT)

Action; Elevate, apply ice packs and observe for 2 hours, Discharge with guidance if symptoms
subside, Consult plastic surgery team if symptoms develop e.g. blistering, parathesiae, altered tissue
perfusion, Complete an incident form
Radiographers Duty of Care

 Radiographers involved or undertaking any contrast examination should;

 Undertake the risk assessment of the patient
 Assess the risk-benefit of individual & seek advice where necessary
 Ensure availability of emergency drugs
 Ensure availability of resuscitation equipment
 Ensure staff are trained to deal with emergencies
 Maintain accurate, up to date records
 Complete incident forms as required