Course Title : VENIPUNCTURE R.A. 9173 2002/ R.A.
7164- the Philippine nursing act of 1991
Course Description: To provide the students an opportunity to develop a
fundamental concept of the skills needed to competently, proficiently, and
safely perform intravenous contrast media administration.
Course Objectives: At the end of the course, student is expected to discuss
legal and ethical aspects of contrast media administration, identify
appropriate venous anatomy and relate correct circulatory physiology,
demonstrate acceptable universal precaution techniques, define and apply
pertinent radiographic pharmacology, perform pertinent patient
assessments, correctly prepare and administer IV contrast media, perform
safe and accurate venipuncture procedures, and recognize and participate
in the care of patients with adverse reactions to IV contrast media.
Credits : 2 Units – 2 Lecture Hours/Week (36 Hours)
Term : Third Year, First Semester
Prerequisite : Human Anatomy and Physiology
Corequisites : Radiologic Contrast Examinations
Professor: Romeo Q. Rivera Jr. RN, MSN
Course Outline:
Venipuncture is the process of obtaining IV access for the purpose of IV
therapy or for blood sampling of venous blood. An invasive procedure and is
carried out for the purpose of:
a. administration of IV contrast media for diagnostic imaging purposes
b. obtain blood for diagnostic purposes
c. monitor levels of blood components
d. administer therapeutic treatments including medications, nutrition
and chemotherapy
e. remove blood due to excess levels of iron or erythrocytes
(hemochromatosis) (polycythemia)
f. to collect blood for later uses, mainly BT in the donor or in another
person.
IV therapy- is insertion of a needle or catheter/ cannula into a vein, based
on the physicians written prescription. The needle or catheter/ cannula is
attached to a sterile tubing and a fluid container to provide medications and
fluids.
I. Legal Aspect of IV Contrast Media and Medication Administration
(2 Hours)
1. Laws and regulations
section 28 states that in administration of IV injections, special
training shall be required.
-IV nursing standards of practice develop by the ANSAP should be
used
2. Institutional policy and procedure- Primum Non Nocere- To do Patient no
harm
2.1. Informed consent- is a process for getting permission before conducting
a healthcare intervention on a person. Taken by the physicians. A radiologic
technologists should be a client advocate
- an informed consent can be said to have been given based upon a clear
appreciation and understanding of the facts, implications and consequences
of an action.
Cases of impairment in reasoning and Judgement that may result to null and
void Informed Consent
1. basic intellectual or emotional maturity
2. high level of stress such as PTSD
3. severe intellectual disability
4. severe mental illness
5. intoxication
6. severe sleep deprivation
7. Alzheimer’s disease or being in a coma
Assent- Giving of informed consent by the legal guardian parents for a
minor patients
Conservators- mentally ill
Elements of informed consent
1. disclosure- to supply adequate information necessary to make an
autonomous decision and have adequate comprehension of the
information provided.
2. Capacity- ability of the subject to both understand the
situation/information provided and form a reasonable judgement
based on the potential consequences of his decisions
3. Voluntariness- refers to the subject’s right to freely exercise his
decision making without being subjected to external pressure such
as coercion, manipulation and undue influence.
Accountability and Professional Obligations
I. Legal and Ethical Issues- Primum non nocere+ to do patient
no harm
a. liability- to be liable is to be legally bound, as to make
good any loss or damage that occurs in the transaction;
 to be an answerable; to responsible
Negligence- is the lack of care or skills that any
health professionals in the same situation would be
expected to use.
Omission to something that a reasonable person
would do.
Malprtactice- any professional misconduct,
unreasonable lack of skill or judgement, or illegally
or immoral conduct.
Tort- legal wrong committed by one person
involving injury to another person, or loss or
damage to property. All person committed tort will
be legally liable.
II. Borrowed servant rule- the doctor is liable for acts of team
members only when he or she has the right to control and
supervise the way which an RT performs the work.
III. Independent contractor- hold an individual responsible for
his acts. Unlike the master-servant rule where in the
employer is held responsible.
IV. Doctrine of The reasonable Man- patient has the right to
expect that all professionals and technical nursing will use
knowledge, skills, and judgment in performing duties that
meet standards exercised by other reasonably prudent
individual involved in similar circumstances.
V. Doctrine of Res Ipsa Loquitor- the things speaks itself
VI. Doctrine of Respondeat superior- master-servant rule
where in the employer is held responsible.
VII. Doctrine of Corporate Negligence- the facility may be liable,
not for the negligence of the employees, but for it’s own
 Fidelity- quality of faithfulness, based on honesty and trust
 Confidentiality- respect for privileged information received
from another person and disclosure only to appropriate
others.
negligence in failing to ensure that an acceptable level of
care is provided.
VIII. Doctrine of Informed refusal- right to withdraw written
consent before the procedure if his or her determination to
do so is reached while in the rational state (right to self
determination).
IX. Doctrine of informed consent- recognizes the physician’s
duty to inform the patient and to obtain consent before the
treatment. Failure to do so may be considered a breach of
duty.
X. Assault and Battery
Assault- is an unlawful threat to harm another physically
Battery – is the carrying out of bodily harms, as by touching
without authorization or consent.
XI. Invasion of privacy- all data concerning clients are
considered confidential
XII. Abandonment- consists of leaving the client for any reason
when the patient’s condition is contingent on the presence
of the caregiver.
Universal Moral Principles Guide in Ethical decision making
 Autonomy- self-determination implies freedom of choice
and ability to make decisions to determine one’s course of
action.
 Beneficence- weighing the pro’s and con’s. benefits must
outweigh the risk of the procedure
 Nonmaleficence- duty to do no harm
 Justice- equality in all care given to different client.
 Veracity- truthfulness
Patient bill of rights
1. The patient has the right to considerate and respectful care.
2. The patient has the right to and is encouraged to obtain from
physicians and other direct caregivers relevant, current, and
understandable information concerning diagnosis, treatment, and
prognosis.
3. The patient has the right to make decisions about the plan of care
prior to and during the course of treatment and to refuse a
recommended treatment or plan of care to the extent permitted by
law and hospital policy and to be informed of the medical
consequences of this action. In case of such refusal, the patient is
entitled to other appropriate care and services that the hospital
provides or transfer to another hospital. The hospital should notify
patients of any policy that might affect patient choice within the
institution.
4. The patient has the right to have an advance directive (such as a
living will, health care proxy, or durable power of attorney for
health care) concerning treatment or designating a surrogate
decision maker with the expectation that the hospital will honor the
intent of that directive to the extent permitted by law and hospital
policy.
5. The patient has the right to every consideration of privacy. Case
discussion, consultation, examination, and treatment should be
conducted so as to protect each patient's privacy.
6. The patient has the right to expect that all communications and
records pertaining to his/her care will be treated as confidential by
the hospital, except in cases such as suspected abuse and public
health hazards when reporting is permitted or required by law.
7. The patient has the right to review the records pertaining to his/her
medical care and to have the information explained or interpreted
as necessary, except when restricted by law.
8. The patient has the right to expect that, within its capacity and
policies, a hospital will make reasonable response to the request of
a patient for appropriate and medically indicated care and services
9. The patient has the right to ask and be informed of the existence of
business relationships among the hospital, educational institutions,
other health care providers, or payers that may influence the
patient's treatment and care.
10. The patient has the right to consent to or decline to participate in
proposed research studies or human experimentation affecting care
and treatment or requiring direct patient involvement, and to have
those studies fully explained prior to consent.
11. The patient has the right to expect reasonable continuity of care
when appropriate and to be informed by physicians and other
caregivers of available and realistic patient care options when
hospital care is no longer appropriate.
12. The patient has the right to be informed of hospital policies and
practices that relate to patient care, treatment, and responsibilities.
Code of Ethics
Ethical behavior
 E arnestness
 T ruthfulness
 H onesty
 I ntegrity
 C onscientiousness
 S incerity
4. Documentation -Clinical documents must be accurate, timely and reflect
specific services provided to a patient. Paper or digital documentation is
often accompanied by supporting electronic files such as magnetic
resonance imaging (MRIs) scans, X-rays, electrocardiograms (EKGs) and
monitoring records.
Clinical documentation is used to facilitate inter-provider communication,
allow evidence-based healthcare systems to automate decisions, provide
evidence for legal records and create patient registry functions so public
health agencies can manage and research large patient populations more
efficiently. Clinical documentation is also used in the creation of longitudinal
patient records (LEPRs), a type of electronic health record (EHR) that
includes all healthcare information from all sources for an individual patient.
2.1 Identification on every page
The following items must appear on every page of the health care record, or
on each screen of an electronic record (with the exception of pop up
screens where the identifying details remain visible behind):
a) Unique identifier (eg. Unique Patient Identifier, Medical Record Number).
b) Patient / client’s family name and given name/s.
c) Date of birth (or gestational age / age if date of birth is estimated).
d) Sex. The exception is ObstetriX records where sex of the mother is not
recorded.

2.2 Standards for documentation
Documentation in health care records must comply with the following:
a) Be clear and accurate.
b) Legible and in English.
c) Use approved abbreviations and symbols.
d) Written in dark ink that is readily reproducible, legible,
and difficult to erase and write over for paper based
records.
e) Time of entry (using a 24-hour clock – hhmm).
f) Date of entry (using ddmmyy or ddmmyyyy).
g) Signed by the author, and include their printed name
and designation. In a computerized system, this will
require the use of an appropriate identification system
eg. Electronic signature.
h) Entries by students involved in the care and treatment
of a patient / client must be cosigned by the student’s
supervising clinician.6
i) Entries by different professional groups are integrated
ie. there are not separate sections for each professional
group.
j) Be accurate statements of clinical interactions between
the patient / client and their significant others, and the
health service relating to assessment; diagnosis; care
planning; management / care / treatment/ services
provided and response / outcomes; professional advice
sought and provided; observation/s taken and results.
k) Be sufficiently clear, structured and detailed to enable
other members of the health care team to assume care
of the patient / client or to provide ongoing service at
any time.
l) Written in an objective way and not include demeaning
or derogatory remarks.
m) Distinguish between what was observed or performed,
what was reported by others as happening and / or
professional opinion Made at the time of an event or as
soon as possible afterwards. The time of writing must
be distinguished from the time of an incident, event or
observation being reported.
n) Sequential - where lines are left between entries they
must be ruled across to indicate they are not left for
later entries and to reflect the sequential and
contemporaneous nature of all entries.
o) Be relevant to that patient / client.
p) Only include personal information about other people
when relevant and necessary for the care and
treatment of the patient / client.
q) Addendum – if an entry omits details any additional
details must be documented next to the heading
‘Addendum’, including the date and time of the omitted
event and the date and time of the addendum.
I. For hardcopy records, addendums must be appropriately
integrated within the record and not documented on
additional papers and / or attached to existing forms.
II. Written in error - all errors are must be appropriately
corrected. No alteration and correction of records is to
render information in the records illegible. An original
incorrect entry must remain readable ie. do not overwrite
incorrect entries, do not use correction fluid. An accepted
method of correction is to draw a line through the incorrect
entry or ‘strikethrough’ text in electronic records; document
“written in error”, followed by the author’s printed name,
signature, designation and date / time of correction.
III. For electronic records the history of audited changes must
be retained and the replacement note linked to the note
flagged as “written in error”. This provides the viewer with
both the erroneous record and the corrected record.
II. Peripheral Circulation Anatomy and Physiology
(4 Hours)
A. Cardiovascular System Functions
1. Transport metabolic substrates from their source (e.g. alimentary tract,
lungs, liver) to the tissues that utilize them (e.g. muscles, brain)
2. Transport metabolic end products (e.g. carbon dioxide, urea, heat) to the
organs that dispose of them (e.g. lungs, kidneys, liver, skin)
3. Transport endocrines from the organs that secret them to their target
tissues
4. Provide a short diffusion distance between the vascular system and the
cells
5. Contribute to maintaining the consistency of the cells' internal
environment (e.g. interstitial fluid) – Homeostasis
B. General Schematic (note pressure drop from arteries to veins)
C. Components
1. Heart: develop the pressure needed to move blood around
the cardiovascular system (overcome blood viscosity);
continuously refresh capillary blood
2. Arteries: distribute blood pumped by the heart to the
microvascular bed
3. Arterioles and associated structures: sites of controlled
resistance; control the flow to individual vascular beds
4. Capillaries: exchange material between blood and
interstitial fluid
5. Venules and Veins: collect blood from vascular beds and
return it to the heart
6. Lymphatics: collect fluid and other substances from tissue
and return it to the circulation
1. Pressure: Force/Area; measured in mmHg (= torr), cmH2O, kPa
(kilopascals); represents potential energy which can be converted to kinetic
energy (movement of blood)
 Systolic pressure: highest pressure in a cardiac chamber or blood
vessel during a cardiac cycle
 Diastolic pressure: lowest pressure in a cardiac chamber or blood
vessel during a cardiac cycle
2. Flow
 volume flow (Q): volume of blood passing a given location in
the circulation per unit time
 Cardiac Output: Q of either ventricle (not both); same as Q
at any level of the circulation (typically 5 liters/min for a
young adult of average size at rest)
 velocity of individual cells in the circulation (v): depends
cross sectional area (A); decreases as A increases
Factors determining Blood Pressure
1.) length of vessel (L): L⇑ ⇒ R⇑
2.) Diameter of vessel (r): r ⇓ ⇒ R⇑
3.) Viscosity of fluid (η): η⇑ ⇒ R⇑
4.) Volume of the blood
5. Heart rate
ARTERIAL SYSTEM
A. Functional Anatomy
1. Heavy, elastic walls: smooth muscle, elastic fibers, fibrous tissue
(loss of tissue results in aneurysm)
2. Low resistance to flow: normal pressure drop required to move
full cardiac output along the total length of the arteries is only
about 2-3 mmHg
B. Normal Pressures
1. Systemic arterial typical value (young adult at rest): 115/75
2. Pulmonary arterial: 22/8 mmHg
C. Pressure Reservoir and Pulse Damping Function
1. Due to elasticity, converts intermittent heart pumping action to
continuously maintained pressure Thus, there is continuous
capillary flow, despite the pulsating nature of cardiac ejection
Note: the arterial pulse wave is what is felt when palpating an artery
Note: Inflow into the arterial system is determined by ventricular
stroke volume. Outflow from the arterial system is determined by
pressure and peripheral resistance (Q = ΔP/R)
2. Arterial pulse pressure (Systolic minus Diastolic) is associated with
the elasticity of the arterial system; since elasticity decreases with
age, pulse pressure generally increases with age
3. Shape of the pulse wave: aorta and large systemic arteries
Pulse = Systolic – Diastolic
Mean = 1/3 Systolic + 2/3 Diastolic (approximate)= Diastolic + 1/3
Pulse
ARTERIOLES AND RELATED VESSELS
A. Functional Anatomy
arteriole: continuous smooth muscle coat 3. Mucosa constrict
metarteriole: arteriole-like vessel, but with intermittent smooth muscle coat 4. Intestine constrict
precapillary sphincters: smooth muscle at the 5. Kidney constrict
beginning of a capillary 6. Skeletal muscle dilate
arterio-venous anastomoses (a-v shunt): direct connections between 7. Liver dilate
arterioles and venules 8. Brain little effect
Note: sympathetic axons innervate arterioles and arterio-venous 9. Lung vessels little effect
anastomoses but not metarterioles or precapillary sphincters 10. Heart little direct effect
11. (indirect dilation)
B. Resistance (systemic arterioles): variable, low to high depending upon
vasomotor state 3. Parasympathetic Nervous System
a. no direct effect (with exceptions)
C. Function: to act as variable resistance valves to distribute blood to each Note: although acetylcholine is an effective vasodilator (through activation
vascular bed accordance with its needs (and the needs of the body) of cholinergic muscarinic receptors), no parasympathetic postganglionic
vasomotion = change in vessel diameter nerves end on blood vessels
vasoconstriction = diameter decrease 􀃎 increase resistance 􀃎 decrease flow b. can have an indirect effect if secretion or other activity stimulated
vasodilation = diameter increase 􀃎 decrease resistance 􀃎 increase flow through release of local vasoactive agents
(or vasodilatation)
4. Relation of arteriolar smooth muscle to nervous innervation
D. Nervous Control (Autonomic Nervous System) a. the effect of nervous activation is diffuse
1. Sympathetic Nervous System b. nerves are only one of many influences on arteriolar smooth muscle
a. mediated by norepinephrine released from postganglionic nerve c. effects of denervation
terminal 1) no loss of structural integrity
b. binds to alpha receptors on arteriole smooth muscle 2) no disability except when reacting to stress
c. action: vasoconstriction (usually) 3) possible development of denervation hypersensitivity
d. functions include (increased sensitivity to circulating agents); due mainly to synthesis
1) arteriole tone at rest of more receptors
2) diversion of blood away from "vegetative" organs in
stress Pathophysiology example: Excess sympathetic activity: Raynaud's disease;
note development of denervation hypersensitivity after postganglionic
2. Adrenal Medulla (activated by sympathetics) denervation
a. mediated by epinephrine released from the adrenal medulla
b. binds to both alpha and beta-2 receptors on arteriole smooth muscle E. Metabolic Control
c. action: depends on whether alpha or beta-2 receptors predominate (all 1. Metabolites
arterioles have alpha receptors but only some tissues have beta-2 carbon dioxide ⇑ 􀃎 vasodilation
receptors) alpha -> vasoconstriction oxygen ⇓ 􀃎 vasodilation
beta-2 -> vasodilation (smooth muscle relax) pH ⇓(or H ion ⇑) 􀃎 vasodilation
Sympathetic + Adrenal Activation 2. Role: automatically adjusts blood flow in accordance
1. Skin constrict with local tissue needs (metabolic autoregulation)
2. Salivary glands constrict
F. Other C. Functions
1. Locally released vasoactive agents (paracrines), e.g. 1. Return blood to the heart
histamine 􀃎 vasodilation
bradykinin 􀃎 vasodilation 2. Act as volume reservoir
nitric oxide 􀃎 vasodilation a. normally contain about 55% of body's total blood
Roles: b. can expel blood to the remaining circulation by venoconstriction
a. inflammation (controlled by the sympathetic system)
b. response to increased tissue activity
2. Myogenic autoregulation 3. Can aid in return of blood to the heart (venous return) by rhythmic
Arteriolar smooth muscle stretch 􀃎 vasoconstriction skeletal muscle contraction (muscle pump) and respiratory movements
3. Temperature: T ⇑ 􀃎 vasodilation (respiratory pump)

CAPILLARIES 4. Some veins are valved; this helps prevent pooling of blood in the veins
A. Functional Anatomy due to gravity
1. small, 5-10 uM inner diameter Pathophysiology note: loss or incompetence of the venous valves can result
2. very thin wall -- single cell layer (promotes diffusion) in enlargement (varicosity)
3. non-contractile
B. Resistance (systemic capillaries): medium 3. Site Selection
C. Function: exchange of substances between blood and interstitial fluid Best sites for Venipuncture
(fluid bathing cells) 1. Median cubital vein- a superficial vein, most commonly used for
venipuncture, it lies over the cubital fossa and serves as
VENULES anastomosis between the cephalic and basilica vein.
A. Functional Anatomy 2. Cephalic vein- shown in both the forearm and arm, it can be
1. Small, but larger than capillaries (in the order of 18 uM inner followed proximally where it empties in the axillary vein.
diameter) 3. Basilica vein- shown in the forearm and arm, it divides to join the
2. Connective tissue and smooth muscle wall brachial vein.
B. Resistance: low
C. Functions Inappropriate Sites for Venipuncture
1. collect blood from capillaries • Arm on side of mastectomy
2. at capillary ends, support diffusion between blood and interstitial • Edematous areas
fluid • Hematomas
• Arm in which blood is being transfused
VEINS • Scarred areas
A. Functional Anatomy • Arms with fistulas or vascular grafts
1. Large diameter • Sites above an IV cannula
2. Connective tissue and smooth muscle (permitting
venoconstriction); less elastic tissue than arteries, so At no time may phlebotomists perform venipuncture in an artery; at no
flaccid when not full; easily distensible time will blood be drawn from the feet unless there is a specific order in
the computer or by the doctor.
B. Resistance: low

3.3. Reason for infusion
3.4. allow 10-15 minutes after a transfusion is completed before obtaining a
blood sample
3.5. Patient factor
III. Universal Precaution
(4 Hours)
CHAIN OF INFECTION
The Chain of Infection describes the development of an infectious process.
An interactive process involving an agent, host, and environment is
required.
The six essential links (elements) in the chain infection
1. Agent- an entity that’s capable of causing a disease
 Biological- living organisms that invade the host, causing disease
such as bacteria, viruses, fungi, protozoa and rickettsia
 Chemical-substances that can interact with the body, causing
disease such as food additives, medications, pesticides and
industrial chemicals
 Physical- factors in the environment that are capable of causing
disease such as heat, light, noise and radiation
2. Reservoir- a place where the agent can survive
 Humans
 Animals
 Environment
 Fomites (objects contaminated with an infectious agents, such as
bedpans, urinals, bed linens, instrument, dressings, specimen
containers, and other equipments0. Carriers have the infectious
agent but are symptom free
3. Portal of exit- the route by which an infectious agent leaves the
reservoir to be transferred to a susceptible host
 Body secretions such as saliva, tears, sputum, semen and vaginal
secretions, feces, urine, blood and from draining wounds
4. Modes of transmission- is he process of the infectious agent moving
from the reservoir through the portal of exit to the portal of entry in a
new susceptible host
 Contact transmission- the most important and frequent mode of
transmission. This involves the transfer of an agent from an infected
individual, indirect contact with an infected person through a
fomite, or close contact with a contaminated secretion.
 Airborne transmission- when a susceptible host contacts droplet
nuclei that are suspended in the air.
 Vehicle transmission- occurs when an agent is transferred to a
susceptible host by contaminated inanimate objects such as water,
food, milk, drugs and blood
 Vector-borne transmission (specific/non-specific)- spread through
animate such as mosquitos, fleas, ticks, lice and other animals. Lyme
disease is spread by specific vector ticks, while flies and cockroaches
are specific vectors.
5. Portal of entry- the route which an infectious agent enters the host
 Skin
 Respiratory
 Genitourinary
 GIT
 Circulatory and
 transplacental
6. Host- an organism that can be affected by the agent
 Susceptible- is a person who has no resistance to an agent and thus
vulnerable to the disease
 Compromised- is a host whose normal body defense are impaired
and is therefore susceptible to infection
General Nursing Care of Communicable Disease Nursing
Breaking the Chain of Infection
Infection control: First Line of Defense- handwashing is the first line of
defense against infection and is he single most important practice in
preventing the spread of infection
Infection control: Cleansing
 Disinfection
 Disinfectants
 Germicide
Sterilization  Fumigation
 Aseptic technique for the instruments, sutures, linens, fluids, and  Disinfection- ( concurrent/ terminal )
other surgical materials  Asepsis
A. Steam autoclaving ISOLATION TECHNIQUE
1. Machine that sterilizes with steam under pressure Definition
2. Normal sterilization cycle, 120C at 20-25 lb pressure for 30 minutes Isolation Technique, a medical aseptic practice,
3. Sterilization of drapes, gown, sheets, towels, lap pads and surgical inhibits the spread and transfer of pathogenic organisms by limiting the
instruments not damaged by intense heat contacts of the patient and creating some kind of physical barrier
4. “flashing” used when critical instrument is dropped; cycle is 270F at 30 between the patient and others.
lb pressure for 4-7 min only Overview
5. Preparations include double wrapping of linen or special paper placed in The original quarantine of infected patients to
a special metal box placed with a filter before sterilization infectious disease hospitals occurred in the late 1800s, but evolved to
B. Ethylene oxide sterilization (gas) isolation rooms by the early 1900s due to increasing knowledge about
Chemical sterilization under carefully controlled time, temperature and microorganisms, infectious diseases and epidemiology of infection. With
humidity condition differential modes of disease transmission, specific categories of isolation
Sterilization of heat labile items such as plastic, finely sharpened became disease-specific precautions, as a means to a more tailored
instruments, suture materials and lenses Needs aeration. A colorless gas, approach to patient uniqueness.
very toxic and flammable
C. Soaking in germicidal solutions ISOLATION TECHNIQUE
Instrument must be dry before immersion. Three hours exposure time is The goal of isolation techniques is to prevent the
needed to destroy spores spread of communicable diseases in hospitals and microorganisms among
 Formalin’s patients, personnel and visitors. These practical techniques evolved to
 Iodophors control cross infection, namely patient to HCW and HCW to patient.
 Benzalkonium chloride Throughout the presentation of safe options to contain and confine disease
 70 % ethyl alcohol transmission, the guidance states facilities are encouraged to modify the
 Glutaraldehyde (cidex) the most common disinfectants isolation recommendations to suit the practice setting and patient needs.
D. Gama irradiations of sutures This adaptation requires explicit written policies and procedures to ensure
Used to sterilize prepacked materials the proper application of the principles in the delivery of services and
Common sources of irradiation are electron beam and cobalt-60 patient care.
E. Millipore filtration of fluids ISOLATION TECHNIQUE
Isolation techniques evolved from the absence of
General Nursing Care of Communicable Disease Nursing any barriers to the current practice of fluid resistant, disposable and
 Prevention- reusable barriers. Known as personal protective equipment (PPE) or
 Health education personal protective attire (PPA), these barriers minimize the risk of bodily
 Immunization fluid exposures to healthcare personnel by protecting skin and mucous
 Environmental sanitation membranes from potentially infective materials. PPE/A are numerous in
 Control design, type, style, size, color and effectiveness in the multifaceted arena of
 Isolation patient care. The selection of appropriate protective attire is dependent on
 Quarantine the procedure to be performed and the anticipated exposure that might
occur. Gloves, mask, gowns, eye protection are the most common personal
protective equipment.
Methods of Physical Protection
Barrier nursing - special nursing procedures which reduce the risks of person
to person transmission, especially by direct contact or by fomites.
Segregation into single rooms, cubicles, or plastic isolators - which reduces
airborne spread to from patients, and facilitates nursing techniques.
Mechanical ventilation - which reduces the risks of airborne spread by
removing bacteria from the patient’s room and by excluding bacteria
present in the outside air from the room.
Types of Isolation
1. High security isolation units - these are usually part of an infectious
diseases hospital. Total environmental control is usually achieved by the use
of negative pressure plastic isolators. These units are designed for treating
Hazard Group 4 viral pathogens such as Lassa, Marburg, and Ebola fevers.
2. Infectious diseases hospitals - these units are usually separate from other
hospitals but may be situated in the grounds of a general hospital with
separate ventilation and nursing staff.
3. General hospital isolation units - these provide source isolation facilities
for hospital-acquired infections; they also provide facilities for protective
isolation and for the screening of patients with suspected infections before
admission to a general ward or transfer to a communicable diseases unit.
4. Single rooms of a general ward - these provide less secure source
isolation than the above because of the close proximity to other patients
and sharing of nursing and domestic staff with a general ward. Their value in
protective isolation depends on the type of patient in the general ward, on
the thoroughness of barrier nursing, on whether the room is self-contained
and on the type of ventilation used.
5. Barrier nursing in open ward - this can be effective in controlling
infections transferred by contact but not by air.
Isolators in open wards - plastic enclosures for individual patients have been
shown to be of value as a form of protective isolation for high risk patients
and of source isolation for infected patients.
Ultra-clean wards - experimental units have been set up in special centers
for organ transplantation, treatment of leukemia and other diseases
associated with extreme susceptibility to infection.
Categories of Isolation
Category A.
These infections are spread by; (1) hands, (2) contact with
non-sterile equipment, feces, blood and body fluids, and (3)
bedpans/urinals. Viruses considered under this category include HIV, HAV,
HBV, HCV, diarrheal viruses and enteroviruses.
Category B.
This category covers infections spread from the respiratory
tract via droplets e.g. chickenpox, measles, mumps. A cubicle or single room
is essential. Masks, gloves, and aprons should be worn when handling the
patient. A ventilation system (consisting of at least an extractor fan) is
advantageous for patients with communicable respiratory infections,
especially chickenpox.
The following general principles apply for category A and B isolation
 Room or cubicle -Room is closed at all times, Furniture is removed
and extraction fan is fitted. Must be equipped with special items
while kept in tidy.
 Gowns and aprons-Gown should be disposable or a water-repellent,
plastic apron should be disinfected by heat or alcohol and should be
left hanging or changed daily or when soiled.
 Gloves - gloves should be worn when handling infected material and
sites and. Conventional disposable non-sterile plastic gloves are
adequate for most purposes. Long sleeved disposable gloves may be
used when protection of the arms is necessary.
 Masks - masks are necessary for category B and perhaps some
category A infections; if used they should be of the high efficiency
filter type, which should provide protection for 10-15 minutes.
 Hands - hand washing before and after contact with the patient
Either a non-medicated soap or a detergent antiseptic preparation
should be adequate for most purposes. 70% alcohol is more
 effective in removing transient as well as residual flora and should
be used in high risk situations.
 The following general principles apply for category A and B isolation
 Bedpans and urinals - gloves should be worn when handling
bedpans and urinals. The contents should be disposed of directly
into the sluice or bedpan disinfector. The bedpan or urinal should
then be heat disinfected and dried. A bedpan washer/disinfector
and a high temperature washing-up machine should be available in
the ward.
 Wastes - all clinical waste should be disposed of in a color-coded
bag for incineration.
 Equipment - disposable or autoclavable equipment should be used
whenever possible. Essential items of patient care such as
sphygmomanometers and stethoscopes should be left in the room
and disinfected when the patient is discharged or before being used
on another patient. Hard surfaces may be disinfected by wiping with
a phenolic, hypochlorite solution, 70% alcohol. Sphygmomanometer
cuffs may be disinfected by low temperature steam. Thermometers
should be kept in the isolation room until the patient is discharged.
 Needles and syringes - these should be disposable and placed in a
hardened container which is sealed before disposal.
 Linen - avoid vigorous bed-making - linen from infected patients
should be placed in a color-coded linen bag for transfer to the
laundry. Linen which may present a hazard to the laundry staff e.g.
hepatitis B should first be sealed in labeled bag.
 The following general principles apply for category A and B isolation
 Crockery and cutlery - disposable items may be used when a
dishwasher heating the items to over 80oC is not available. Food
should be placed in polythene bags and discarded with ward waste.
 Laboratory specimens - some warning should be given to the
laboratory staff. Containers should be placed in a biohazard bag.
 Charts - patient’s charts should be kept outside the contaminated
areas.
 Disposal of personal clothing - clean clothing requires no special
treatment. Contaminated or fouled clothing should be transferred
to the hospital laundry in a sealed water-soluble or alginate-stitched
bag. Clothing from patients with viral hemorrhage fever require
special arrangement.      Strict Isolation - this is designed to prevent transmission of highly
 Transporting patients - patients should be sent to other
departments only if it is essential to do so. The department should
be notified in advance so that they may take suitable measures to
prevent the spread of infection.
Category C. (Reverse - Protective Isolation)
This is used for diseases in which there is increased susceptibility to
infection such as patients with neutropenia, on anti-cancer chemotherapy,
and severely immune-compromised patients. The amount of protection
required varies with the type of patient. Essentially, such patients should be
isolated with a minimum of dust, dirt, and wet areas. Hands must be
washed or disinfected before entering the room. Sterile gloves, gown or
apron, and masks should be worn and discarded after attending patient.
Maximum protection, including sterile linen, food and other supplies, may
be required for immunosuppressed patients, but is not necessary for
patients with eczema and burns. Maximum protective isolation requires the
use of a ventilated room or positive pressure isolator. Mouth and other
orifices should be decontaminated, gut and skin may also have to be
decontaminated. Staff should wear sterile protective clothing. If visitors are
admitted to the isolation room, they should be given detailed instructions
and if suffering from any infection, they should be excluded.  
Category D. (Strict Isolation)
Category D isolation is only found in specialized units for
highly contagious infections such as rabies and viral hemorrhagic fevers. A
cubicle is essential (a plastic bubble that contains the patient and all
essential patient-care equipment) may be used. Gowns, plastic aprons,
masks, and eye goggles should be worn. Crockery and cutlery should be
disposable. Disposable non-clinical articles should be used and should not
be recycled. All other clinical equipment should be sterilized. Air-borne
contamination and patient-handling should be kept to a minimum. Hospital
staff and visitors should be made aware of the risks when tending such
patients.
Other Isolation Procedure Classification
contagious or virulent infections that may be spread by air or
contact. This is recommended for chickenpox as well as for viral
 hemorrhagic fevers. A private room is required and gowns, masks,
and gloves must be worn before entry. Hands must be washed after
leaving the room and contaminated articles should be discarded or
bagged and labeled before being sent for decontamination and
reprocessing.
 Contact Isolation - this is designed to prevent transmission of highly
transmissible or epidemiologically important infections that do not
warrant strict isolation. All diseases included in this category are
spread primarily by close or direct contact such as HSV and
respiratory infections in infants and young children. Private room is
indicated although patients infected with the same organism may
share a room. Masks are indicated for those who come close to the
patient. Gowns are indicated if soiling is likely. Gloves are indicated
for touching infective material. Hands must be washed after
touching the patient or potentially contaminated articles and before
taking care of another patient. Articles contaminated with infective
material should be discarded or bagged and labeled.
 Respiratory Isolation - this is designed to prevent transmission of
infectious diseases over short distances through the air. Direct and
indirect contact transmission may occur but is infrequent. Diseases
requiring respiratory isolation include measles, mumps, and rubella.
Private room is indicated although patients infected with the same
organism may share a room. Masks are indicated for those who
come in close contact with the patient. Gowns and gloves are not
indicated. Hands must be washed after touching the patient or
contaminated articles, and contaminated articles should be
discarded or bagged and labeled.
 Enteric Precautions - enteric precautions are designed to prevent
infections that are transmitted by direct or indirect contact with
feces. Diarrheal viruses, hepatitis A, and enteroviruses are included
in this category. A private room is indicated if patient hygiene is
poor and thus at risk of contaminating others. Masks are not
indicated. Gowns are not indicated if soiling is likely. Gloves should
be used for touching infective material. Hands must be washed after
touching the patient or contaminated articles, and contaminated
articles should be discarded or bagged and labeled.
 Blood/body fluid precautions -prevent infections that are
transmitted by contact with blood or other body fluids such as HIV
and HBV. A private room is indicated if patient hygiene is poor
because of the higher risk to others. Gowns are only indicated f
soiling is likely. Masks are not indicated but gloves should be worn.
Hands must be washed after touching the patient or contaminated
articles, and contaminated articles should be discarded or bagged
and labeled. avoid needle-stick injuries. Needles should be placed in
a prominently labeled, puncture-resistant container designated
specifically for such disposal. Blood spills should be cleaned up
promptly with hypochlorite.
 Drainage/Secretion Precautions - prevent infections that are
transmitted by direct or indirect contact with purulent material or
drainage from an infected body site. Gowns are only indicated if
soiling is likely. gloves should be worn. Hands must be washed after
touching the patient or contaminated articles, and contaminated
articles should be discarded or bagged and labeled.
 Isolation methods for individual viral diseases  
CENTER FOR DISEASE CONTROL PRECAUTIONS
Standard Precautions (use for all Patients)
 Handwashing- wash hands before contact with each client, during
care as needed (even if wearing gloves) to prevent cross
contamination of body sites, and after teaching blood, body fluids
and secretions, excretions and contaminated items (with or without
gloves)
 Gloves- wear gloves (clean, nonsterile adequate) whenever contact
is expected with blood, body fluids, secretions, excretions, mucous
membranes and non-intact skin and contaminated items. Always
change gloves between clients and between tasks and procedure on
the same client after contact with the material that may contain a
high concentration of organisms. Remove gloves promptly after use,
before touching non-contaminated items and environmental
surfaces, and before going to other client, wash hands
  Face protection ( mask, goggles, face shield)- wear a face shield,
goggles, mask that covers both the nose and the mouth during
procedures and client care activities that are likely to generate
splashes or sprays of the blood, body fluids, secretions, or
excretions to provide protection of the mucous membranes of the
mouth eyes and nose.
 In all areas and places specifically the clinical area , all person that
you came in contact with is considered potentially communicable.
Extreme caution should be considered and practice of asepsis
should always be applied to break the chain of infection.
IV. Contrast Media and Pertinent Radiographic Pharmacology
(6 Hours)
A medical contrast medium (or contrast agent) is a substance used to
enhance the contrast of structures or fluids within the body in medical
imaging.[1] It is commonly used to enhance the visibility of blood vessels and
the gastrointestinal tract.
Types
Several types of contrast media are in use in medical imaging and they can
roughly be classified based on the imaging modalities where they are used.
Although other types exist, most common contrast agents work based on X-
ray attenuation and magnetic resonance signal enhancement.
X-ray attenuation
Main article: Radiocontrast agent
Iodine and barium are the most common types of contrast medium for
enhancing x-ray-based imaging methods. Various sorts of iodinated contrast
media exist, with variations occurring between the osmolarity, viscosity and
absolute iodine content of different media. Non-ionic dimers are favored for
their low osmolarity and toxicity, but have a correspondingly higher price
attached to their use.[2]
MR signal enhancing
Main article: MRI contrast agent
Gadolinium is used in magnetic resonance imaging as a MRI contrast agent.
[3]
In the 3+ oxidation state the metal has 7 unpaired f electrons. This causes
water around the contrast agent to relax quickly, enhancing the quality of
the MRI scan.
Ultrasound scattering and frequency shift
Main article: Contrast-enhanced ultrasound
Microbubble contrast agents are used to aid the sonographic examination,
specifically echocardiograms, for the detection of a cardiac shunt. These
bubbles are composed of agitated saline solution, most of which are too
large to pass through the lung capillaries. Therefore, the only ones that
reach the left side of the heart pass through an abnormal connection
between the two sides of the heart, a so-called right-to-left shunt. In
addition, pharmaceutically prepared microbubbles are composed of tiny
amounts of nitrogen or perfluorocarbons strengthened and supported by a
protein, lipid, or polymer shell. These are small enough to pass through the
capillaries and are used to increase the contrast in the left ventricle,
improving the visualization of its walls. The drop in density on the interface
between the gas in the bubble and the surrounding liquid strongly scatters
and reflects the ultrasound back to the probe. This process of backscattering
gives the liquid with these bubbles a high signal, which can be seen in the
resulting image.
Adverse effects
While modern contrast media are generally safe to use, [2] medical conditions
can be caused by the administration of various contrast media. Reactions
can range from minor to severe, sometimes resulting in death [4] with death
being about 0.9 per 100,000 cases. To better understand the reactions and
to efficiently manage patients at risk, it is useful to classify them. [5] Risk
factors for developing severe reactions include strong allergies, bronchial
asthma, cardiac disease and beta-blocker use. [6][7] While the previously
suspected IL-2 medication is no risk for the acquisition of adverse events. [8]
A common misconception that even exists among healthcare professionals
is that an allergy to contrast media is related to an allergy to seafood
(usually shellfish) because both share iodine in their construction,
implicating iodine as a source. [9][10] Numerous studies have shown that
although iodine is common in contrast media, iodine is not the cause of
allergic reactions to contrast media and instead the more likely culprit are
the inert ingredients and the patient's past history of having other strong
allergic reactions.[11] One important distinction is that allergic effects are by
definition immunoglobulin E related histamine storms and studies have
shown that contrast media cause no such reaction in vivo [12] thereby
refuting the possibility that contrast media or the iodine in it is likely to be
an allergen. Although it may seem contradictory, the few rare cases of
contrast medium mediated IgE are exceedingly rare compared to all adverse
reactions and when they happen, are often because the patient already has
multiple risk factors that suggest the patient has other allergy related
problems.[6]
Historically, contrast media was sometimes highly dangerous but these
dangers were not well-understood during the development of the early
types of contrast media, such as Thorotrast.
1. Radiocontrast agents are a type of medical contrast medium used to
improve the visibility of internal bodily structures in X-ray-based imaging
techniques such as computed tomography (CT), radiography, and
fluoroscopy. Radiocontrast agents are typically iodine or barium
compounds. When an agent improves visibility of an area, it is called
"contrast enhancing".
Magnetic resonance imaging (MRI) functions through different principles
and thus utilizes different contrast agents. These compounds work by
altering the magnetic properties of nearby hydrogen nuclei.
Types and uses
Radiocontrast agents used in X-ray examinations can be grouped based on
its use.
Iodinated (intravascular)
Example of iodine based contrast in cerebral angiography
Iodine-based contrast media are usually classified as ionic or non-ionic. Both
types are used most commonly in radiology due to their relatively harmless
interaction with the body and its solubility. Contrast media are primarily
used to visualize vessels and changes in tissues on radiography and CT.
Contrast media can also be used for tests of the urinary tract, uterus and
fallopian tubes. It may cause the patient to feel as if he or she has urinated
on him- or herself. It also puts a metallic taste in the mouth of the patient.
Modern intravenous contrast agents are typically based on iodine. This may
be bound either in an organic (non-ionic) compound or an ionic compound.
Ionic agents were developed first and are still in widespread use depending
on the requirements, but may result in additional complications. Organic
agents which covalently bind the iodine have fewer side effects as they do
not dissociate into component molecules. Many of the side effects are due
to the hyperosmolar solution being injected. i.e. they deliver more iodine
atoms per molecule. The more iodine, the more "dense" the X-ray effect.
There are many different molecules. Some examples of organic iodine
molecules are iohexol, iodixanol and ioversol. Iodine-based contrast media
are water-soluble. These contrast agents are sold as clear, colorless water
solutions, with the concentration usually expressed as mg I/ml. Modern
iodinated contrast agents can be used almost anywhere in the body. Most
often they are used intravenously, but for various purposes they can also be
used intraarterially, intrathecally (as in diskography of the spine) and
intraabdominally – just about any body cavity or potential space.
Iodine contrast agents are used for the following: Commonly used iodinated contrast agents

 Angiography (arterial investigations) Iodine

Compound Name Type Osmolality
 Venography (venous investigations) content
 VCUG (voiding cystourethrography)
350)
 HSG (hysterosalpingogram)
 IVU (intravenous urography) Non-ionic Ioxilan (Oxilan 350) Monomer 350 mgI/ml 695 Low

Ionic Iopromide (Ultravist

Non-ionic Monomer 370 mgI/ml 774 Low
370)
Ionic contrast media typically, but not always, have higher osmolality and
Iodixanol (Visipaque
more side-effects.[citation needed] Non-ionic Dimer 320 mgI/ml 290 Low
320)

Commonly used iodinated contrast agents

Barium (gastro-intestinal)
Iodine
Compound Name Type Osmolality
content

Diatrizoate (Hypaque
Ionic Monomer 300 mgI/ml 1550 High
50)

Metrizoate (Isopaque
Ionic Monomer 370 mgI/ml 2100 High
370)

Ionic Ioxaglate (Hexabrix) Dimer 320 mgI/ml 580 Low

Non-ionic

Non-ionic contrast media have lower osmolality and tend to have fewer
side-effects.[citation needed]
Example of a DCBE

Commonly used iodinated contrast agents Barium sulfate is mainly used in the imaging of the digestive system. The
substance exists as a water-insoluble white powder that is made into a
Iodine
Compound Name Type Osmolality slurry with water and administered directly into the gastrointestinal tract.
content

Iopamidol (Isovue  Barium enema (large bowel investigation) and DCBE (double
Non-ionic Monomer 370 mgI/ml 796 Low
370) contrast barium enema)
 Barium swallow (oesophagael investigation)
Non-ionic Iohexol (Omnipaque Monomer 350 mgI/ml 884 Low
  Barium meal (stomach investigation) and double contrast barium
meal
 Barium follow through (stomach and small bowel investigation)
 CT pneumocolon / virtual colonoscopy
Barium sulfate, an insoluble white powder is typically used for enhancing
contrast in the GI tract. Depending on how it is to be administered the
compound is mixed with water, thickeners, de-clumping agents, and
flavourings to make the contrast agent. As the barium sulfate doesn't
dissolve, this type of contrast agent is an opaque white mixture. It is only
used in the digestive tract; it is usually swallowed or administered as an
enema. After the examination, it leaves the body with the feces.
Air
As in the picture on the right where both air and barium are used together
(hence the term "double-contrast" barium enema) air can be used as a
contrast material because it is less radio-opaque than the tissues it is
defining. In the picture it highlights the interior of the colon. An example of
a technique using purely air for the contrast medium is an air arthrogram
where the injection of air into a joint cavity allows the cartilage covering the
ends of the bones to be visualized.
Before the advent of modern neuroimaging techniques, air or other gases
were used as contrast agents employed to displace the cerebrospinal fluid
in the brain while performing a pneumoencephalography. Sometimes called
an "air study", this once common yet highly-unpleasant procedure was used
to enhance the outline of structures in the brain, looking for shape
distortions caused by the presence of lesions.
Carbon Dioxide
Carbon dioxide also has a role in angiography. It is low-risk as it is a natural
product with no risk of allergic potential. However, it can be used only
below the diaphragm as there is a risk of embolism in neurovascular
procedures. It must be used carefully to avoid contamination with room air
when injected. It is a negative contrast agent in that it displaces blood when
injected intravascularly.
Other
An older type of contrast agent, Thorotrast was based on thorium dioxide.
While it provided excellent image enhancement, its use was abandoned
since it turned out to be highly carcinogenic, unfortunately though not
before having been administered to millions of patients prior to being
disused.
Adverse effects
Modern iodinated contrast agents are generally well tolerated. [1] The major
side effects of radiocontrast are anaphylactoid reactions and contrast-
induced nephropathy.
Anaphylactoid reactions
Anaphylactoid reactions occur rarely,[2][3][4] but can occur in response to
injected as well as oral and rectal contrast and even retrograde
pyelography. They are similar in presentation to anaphylactic reactions, but
are not caused by an IgE-mediated immune response. Patients with a
history of contrast reactions, however, are at increased risk of
anaphylactoid reactions.[5][6] Pretreatment with corticosteroids has been
shown to decrease the incidence of adverse reactions. [7][8]
Anaphylactoid reactions range from urticaria and itching, to bronchospasm
and facial and laryngeal edema. For simple cases of urticaria and itching,
Benadryl (diphenhydramine) oral or IV is appropriate. For more severe
reactions, including bronchospasm and facial or neck edema, albuterol
inhaler, or subcutaneous or IV epinephrine, plus diphenhydramine may be
needed. If respiration is compromised, an airway must be established prior
to medical management.
Anaphylaxis to ionic (high osmolar) contrast agent injections that occurred
in two clusters of reactions on two occasions (1983 and 1987) in a single
radiology clinic in London Ontario. On each occasion, these anaphylactic
reactions were associated with contamination of the injection by natural
rubber components (disposable plastic syringes in the first case and rubber
ampoule seals in the second case). The allergenic-toxic rubber leachate was
MBT (mercaptobenzothiazole). This is a known allergen that becomes
bound to plasma proteins, creating a hapten-protein complex – a signature
mechanism in true IgE drug allergy and true anaphylactic reactions (not
"anaphylactoid" reactions).
A Japanese syringe manufacturer, Terumo, implicated in syringe-related
toxic laboratory cell culture effects in Australia in 1981, was instrumental in
pro-actively making Japanese disposable syringes and ampoule seals free of
natural rubber. Katayama's 1990 article in Radiology showed that a new
type of nonionic (low osmolar) contrast agent was associated with
significantly fewer severe life-threatening reactions than the older ionic
(high osmolar) contrast agents.[9] By merchandizing the Katayama series
reprints, manufacturers persuaded users worldwide to switch to the almost
exclusive use of the expensive nonionic agents.
What was unknown to the Katayama researchers was that the ampoule
seals of the "safer" nonionic contrast agents were made from artificial
rubber, whereas the ionic agents were sealed with natural rubber. In 1987,
it was the leaching of allergenic MBT from the rubber seals of ionic
ampoules that caused a series of allergic reactions (including anaphylaxis) in
a radiology office in Canada. [10] The worldwide hazard of MBT contamination
of injections was unknown then and, as the World Health Organization
reported it remains as an unknown hazard still – after three decades. [11]
The most significant study, proving that injections of ionic (high osmolar)
agents are at least as safe as the newer, very expensive nonionics was
published in Radiology in 1997.[12] Lasser did not comment that the marked
drop in the incidence of severe reactions with ionic agents was related to
the removal of natural rubber contamination from ionic ampoule seals.
Contribution of seafood and other allergies
There are no true allergies against iodine. Suspicion of seafood "allergy" is
not a sufficient contraindication to the use of iodinated contrast material.
While iodine levels in seafood are higher than in non-seafood items, the
consumption of the latter exceeds that of the former by far and there is no
evidence that the iodine content of seafood is related to reactions to
seafood.[13] Available data suggest that seafood allergy increases the risk of a
contrast-mediated reaction by approximately the same amount as allergies
to fruits or those with asthma. [14] In other words, over 85% of patients with
seafood allergies will not have an adverse reaction to iodinated contrast. [13]
Finally, there is no evidence that adverse skin reactions to iodine-containing
topical antiseptics (e.g., povidone-iodine) are of any specific relevance to
administration of I.V. contrast material.[13][15]
Contrast-induced nephropathy
Main article: Contrast-induced nephropathy
Contrast-induced nephropathy is defined as either a greater than 25%
increase of serum creatinine or an absolute increase in serum creatinine of
0.5 mg/dL.[16]
Effects on thyroid function
A 2012 paper in the Journal of the American Medical Association reports
that "Iodinated contrast media exposure is associated with subsequent
development of incident hyperthyroidism and incident overt
hypothyroidism."[1][2] This is presumably an effect specifically of ionic
compounds, which dissociate to produce free radicals, biologically active
iodide ions rather than non-ionic compounds, in which iodine remains
covalently bound and hence biologically unavailable.
Drug interactions
It has been recommended[17] that metformin, an oral antidiabetic agent, be
stopped for 48 hours following the intravascular administration of contrast
media and that the use of metformin not be resumed until renal function
has been shown to be normal. The reasoning is that if the contrast medium
causes kidney failure (as happens rarely) and the person continues to take
metformin (which is normally excreted by the kidneys), there may be a toxic
accumulation of metformin, increasing the risk of lactic acidosis, a
dangerous complication.
However, guidelines published by the Royal College of Radiologists suggest
this is not as important for patients who receive less than 100 ml of contrast
media and have normal renal function. If renal impairment is found before
administration of the contrast, metformin should be stopped 48 hours
before and after the procedure.
MRI contrast agents are a group of contrast media used to improve the
visibility of internal body structures in magnetic resonance imaging (MRI).[1]
The most commonly used compounds for contrast enhancement are
gadolinium-based. Such MRI contrast agents shorten the relaxation times of
atoms within body tissues following oral or intravenous administration. In
MRI scanners, sections of the body are exposed to a very strong magnetic
field causing primarily the hydrogen nuclei ("spins") of water in tissues to be
polarized in the direction of the magnetic field. An intense radiofrequency
pulse is applied that tips the magnetization generated by the hydrogen
nuclei in the direction of the receiver coil where the spin polarization can be
detected. Random molecular rotational oscillations matching the resonance
frequency of the nuclear spins provide the "relaxation" mechanisms that
bring the net magnetization back to its equilibrium position in alignment
with the applied magnetic field. The magnitude of the spin polarization
detected by the receiver is used to form the MR image but decays with a
characteristic time constant known as the T1 relaxation time. Water protons
in different tissues have different T1 values, which is one of the main
sources of contrast in MR images. A contrast agent usually shortens, but in
some instances increases, the value of T1 of nearby water protons thereby
altering the contrast in the image.
 4 External links
Types
Most clinically used MRI contrast agents work by shortening the T1
relaxation time of protons inside tissues via interactions with the nearby
contrast agent. Thermally driven motion of the strongly paramagnetic metal
ions in the contrast agent generate the oscillating magnetic fields that
provide the relaxation mechanisms that enhance the rate of decay of the
induced polarization. The systematic sampling of this polarization over the
spatial region of the tissue being examined forms the basis for construction
of the image.
MRI contrast agents may be administered by injection into the blood stream
or orally, depending on the subject of interest. Oral administration is well
suited to G.I. tract scans, while intravascular administration proves more
useful for most other scans. A variety of agents of both types enhance scans
routinely.
MRI contrast agents can be classified in many ways, [2] including by their:

Contents 1. chemical composition

2. administration route
 1 Types 3. magnetic properties
o 1.1 Gadolinium (Gd): Paramagnetic 4. effect on the image
 1.1.1 Types of gadolinium contrast agents 5. presence and nature of metal atoms
 1.1.1.1 Extracellular fluid agents 6. biodistribution and applications:
 1.1.1.2 Blood pool agents 1. Extracellular fluid agents (also known as intravenous
 1.1.1.3 Organ-specific agents contrast agents)
 1.1.2 Gadolinium-containing contrast agents 2. Blood pool agents (also known as intravascular contrast
approved for human use agents)
 1.1.3 Safety of gadolinium contrast agents 3. Organ specific agents (i.e. gastrointestinal contrast agents
o 1.2 Iron oxide: Superparamagnetic and hepatobiliary contrast agents)
o 1.3 Iron Platinum: Superparamagnetic 4. Active targeting/cell labeling agents (i.e. tumor-specific
o 1.4 Manganese: Paramagnetic agents)
o 1.5 Oral administration of contrast agents 5. Responsive (also known as smart or bioactivated) agents
o 1.6 Protein-based MRI contrast agents 6. pH-sensitive agents
 2 See Also
 3 References Gadolinium (Gd): Paramagnetic
For other uses of the abbreviation "GAD" in medicine, see Gad. 1. Albumin-binding gadolinium complexes (i.e. Ablavar and
Gadocoletic acid)
2. Polymeric gadolinium complexes (i.e. Gadomelitol and Gadomer 17)

Organ-specific agents

(i.e. Primovist™ and Multihance which are used as hepatobiliary agents)

Gadolinium-containing contrast agents approved for human use

Effect of contrast agent on images: Defect of the blood–brain barrier after
stroke shown in MRI. T1-weighted images, left image without, right image
Presently, nine different types of gadolinium-containing contrast agents are
with contrast medium administration.
available in different territories. In European countries, Gd chelated contrast
agents approved by the European Medicines Agency (EMA) include:[4]
Gadolinium(III) containing MRI contrast agents (often termed simply "gado"
or "gad") are the most commonly used for enhancement of vessels in MR
 gadoterate (Dotarem)
angiography or for brain tumor enhancement associated with the
 gadodiamide (Omniscan)
degradation of the blood–brain barrier. For large vessels such as the aorta
 gadobenate (MultiHance)
and its branches, the gadolinium(III) dose can be as low as 0.1 mmol per kg
 gadopentetate (Magnevist, Magnegita, Gado-MRT ratiopharm)
body mass. Higher concentrations are often used for finer vasculature. [3]
 gadoteridol (ProHance)
Gd(III) chelates do not pass the blood–brain barrier because they are
 gadoversetamide (OptiMARK)
hydrophilic. Thus, these are useful in enhancing lesions and tumors where
 gadoxetate (Primovist)
the Gd(III) leaks out. In the rest of the body, the Gd(III) initially remains in
 gadobutrol (Gadovist)
the circulation but then distributes into the interstitial space or is eliminated
by the kidneys.
In the United States of America, Gd chelated contrast agents approved by
the U.S. Food and Drug Administration (FDA) include:[5]
Types of gadolinium contrast agents
 gadoterate (Dotarem)
Gadolinium(III) contrast agents can be categorized into:
 gadodiamide (Omniscan)
 gadobenate (MultiHance)
Extracellular fluid agents
 gadopentetate (Magnevist)
 gadoteridol (ProHance)
 Dotarem
 gadofosveset (Ablavar, formerly Vasovist)
 Magnetol
 gadoversetamide (OptiMARK)
 Gadavist
 gadoxetate (Eovist)
 Magnevist
 gadobutrol (Gadavist)
 Omniscan
 OptiMARK
Safety of gadolinium contrast agents
 Prohance
Main article: Nephrogenic systemic fibrosis
Blood pool agents
Gadolinium MRI contrast agents have not proved safer than the iodinated
contrast agents used in X-ray radiography or computed tomography as they
are nephrotoxic and neurotoxic. Because gadolinium-based contrasting
agents pass the blood–brain barrier and of each bolus dose at least 1% of
the gadolinium is retained and assumed to be in its free toxic state; these
products need further study. Anaphylactoid reactions are rare, occurring in
approx. 0.03–0.1%.[6]
As a free solubized aqueous ion, gadolinium (III) is somewhat toxic, but was
generally regarded as safe when administered as a chelated compound. In
animals the free Gd (III) ion exhibits a 100–200 mg/kg 50% lethal dose, but
the LD50 is increased by a factor of 100 when Gd (III) is chelated, so that its
toxicity becomes comparable to iodinated X-ray contrast compounds. [7] The
chelating carrier molecule for Gd for MRI contrast use can be classified by
whether they are macro-cyclic or have linear geometry and whether they
are ionic or not. Cyclical ionic Gd(III) compounds are considered the least
likely to release the Gd(III) ion, and hence the safest. [8] However, the use of
some Gd(III) chelates in persons with renal disease was linked to a rare but
severe complication, nephrogenic fibrosing dermopathy,[9] also known as
nephrogenic systemic fibrosis (NSF).[9][10][11] This systemic disease resembles
scleromyxedema and to some extent scleroderma. It may occur months
after contrast has been injected. [12] Patients with poorer renal function are
more at risk for NSF, with dialysis patients being more at risk than patients
with renal insufficiency.[13][14] After several years of controversy during which
up to 100 Danish patients have been gadolinium poisoned (and some died)
after use of the contrast agent Omniscan, it was admitted by the Norwegian
medical company Nycomed that they were aware of some dangers of using
gadolinium-based agents for their product. [15] At present, NSF has been
linked to the use of four gadolinium-containing MRI contrast agents. The
World Health Organization issued a restriction on use of several gadolinium
contrast agents in November 2009 stating that "High-risk gadolinium-
containing contrast agents (Optimark, Omniscan, Magnevist, Magnegita and
Gado-MRT ratiopharm) are contraindicated in patients with severe kidney
problems, in patients who are scheduled for or have recently received a
liver transplant, and in newborn babies up to four weeks of age." [16]
Iron oxide: Superparamagnetic
Two types of iron oxide contrast agents exist: superparamagnetic iron oxide
(SPIO) and ultrasmall superparamagnetic iron oxide (USPIO). These contrast
agents consist of suspended colloids of iron oxide nanoparticles and when
injected during imaging reduce the T2 signals of absorbing tissues. SPIO and
USPIO contrast agents have been used successfully in some instances for
liver tumor enhancement.[17] Although SPIOs and USPIOs have been
approved for use in the past, it appears that all of the agents listed below
are no longer available with the exception of the oral iron oxide contrast
agent, Lumirem/Gastromark.
 Feridex I.V. (also known as Endorem and ferumoxides). This product
was discontinued by AMAG Pharma in November 2008. [18]
 Resovist (also known as Cliavist). This was approved for the
European market in 2001, but production was abandoned in 2009.
[19]
 Sinerem (also known as Combidex). Guerbet withdrew the
marketing authorization application for this product in 2007. [20]
 Lumirem (also known as Gastromark). Gastromark was approved by
the FDA in 1996.[21]
 Clariscan™ (also known as PEG-fero, Feruglose, and NC100150).
Development was discontinued due to safety concerns. [22]
Iron Platinum: Superparamagnetic
Superparamagnetic iron platinum particles (SIPPs) have been reported and
had significantly better T 2 relaxivities compared with the more common iron
oxide nanoparticles. SIPPs were also encapsulated with phospholipids to
create multifunctional SIPP stealth immunomicelles that specifically
targeted human prostate cancer cells. [23] These are, however, investigational
agents which have not yet been tried in humans. In a recent study,
multifunctional SIPP micelles were synthesized and conjugated to a
monoclonal antibody against prostate-specific membrane antigen. [23] The
complex specifically targeted human prostate cancer cells in vitro, and these
results suggest that SIPPs may have a role in the future as tumor-specific
contrast agents.
Manganese: Paramagnetic
Unlike the other well-studied iron oxide-based nanoparticles, research on
Mn-based nanoparticles is at a relatively early stage. [24] Manganese chelates
such as Mn-DPDP enhance the T 1 signal and have been used for the
detection of liver lesions. The chelate dissociates in vivo into manganese
and DPDP where the former is absorbed intra-cellularly and excreted in bile,
while the latter is eliminated via the renal filtration. [25]
Manganese ions (Mn2+) are often used as a contrast agent in animal studies,
usually referred to as MEMRI (Manganese Enhanced MRI). [26] Due to the
ability of Mn2+ to enter cells through Calcium Ca 2+ channels Mn2+ can e.g. be
used for functional brain imaging.[27]
2+
Recently, Mn carbon nanostructure complexes of graphene oxide
nanoplatelets[28] and graphene oxide nanoribbons have been reported as
high-performance magnetic resonance imaging contrast agents. [29]
1.1.1 Assess and manage patients' fluid and electrolyte needs as part of
every ward review. Provide intravenous (IV) fluid therapy only for patients
whose needs cannot be met by oral or enteral routes, and stop as soon as
possible.
1.1.2 Skilled and competent healthcare professionals should prescribe and
administer IV fluids, and assess and monitor patients receiving IV fluids
1.1.3 When prescribing IV fluids, remember the 5 Rs: Resuscitation, Routine
maintenance, Replacement, Redistribution and Reassessment.
1.1.4 Offer IV fluid therapy as part of a protocol

Oral administration of contrast agents
A wide variety of oral contrast agents can enhance images of the
gastrointestinal tract. They include gadolinium and manganese chelates, or
iron salts for T1 signal enhancement. SPIO, barium sulfate, air and clay have
been used to lower T2 signal. Natural products with high manganese
concentration such as blueberry and green tea can also be used for T1
increasing contrast enhancement.[30]
Perflubron, a type of perfluorocarbon, has been used as a gastrointestinal
MRI contrast agent for pediatric imaging. [31] This contrast agent works by
reducing the number of hydrogen ions in a body cavity, thus causing it to
appear dark in the images.
 Assess patients' fluid and electrolyte needs following Algorithm 1:
Assessment.
 If patients need IV fluids for fluid resuscitation, follow Algorithm 2:
Fluid resuscitation.
 If patients need IV fluids for routine maintenance, follow
Algorithm 3: Routine maintenance.
 If patients need IV fluids to address existing deficits or excesses,
ongoing abnormal losses or abnormal fluid distribution, follow
Algorithm 4: Replacement and redistribution.
Algorithms for IV fluid therapy

Protein-based MRI contrast agents

Newer research suggests the possibility of protein based contrast agents,

based on the abilities of some amino acids to bind with gadolinium

Principles and protocols for intravenous fluid therapy

The assessment and management of patients' fluid and electrolyte needs is

fundamental to good patient care.
1.1.5 Include the following information in IV fluid prescriptions:

 The type of fluid to be administered.

 The rate and volume of fluid to be administered.

1.1.6 Patients should have an IV fluid management plan, which should

include details of:

 the fluid and electrolyte prescription over the next 24 hours

 the assessment and monitoring plan.

Initially, the IV fluid management plan should be reviewed by an

expert daily. IV fluid management plans for patients on longer-term
IV fluid therapy whose condition is stable may be reviewed less
frequently.

1.1.7 When prescribing IV fluids and electrolytes, take into account all other
sources of fluid and electrolyte intake, including any oral or enteral intake,
and intake from drugs, IV nutrition, blood and blood products.

1.1.8 Patients have a valuable contribution to make to their fluid balance. If

a patient needs IV fluids, explain the decision, and discuss the signs and
symptoms they need to look out for if their fluid balance needs adjusting. If
possible or when asked, provide written information (for example, NICE's
Information for the public), and involve the patient's family members or
carers (as appropriate).

1.2 Assessment and monitoring

Initial assessment

1.2.1 Assess whether the patient is hypovolaemic. Indicators that a patient

may need urgent fluid resuscitation include:

 systolic blood pressure is less than 100 mmHg

 heart rate is more than 90 beats per minute
  capillary refill time is more than 2 seconds or peripheries are cold to
touch
 respiratory rate is more than 20 breaths per minute
 National Early Warning Score (NEWS) is 5 or more
 passive leg raising suggests fluid responsiveness [1].
1.2.2 Assess the patient's likely fluid and electrolyte needs from their
history, clinical examination, current medications, clinical monitoring and
laboratory investigations:
 History should include any previous limited intake, thirst, the
quantity and composition of abnormal losses (see Diagram of
ongoing losses), and any comorbidities, including patients who are
malnourished and at risk of refeeding syndrome (see Nutrition
support in adults [NICE clinical guideline 32]).
 Clinical examination should include an assessment of the patient's
fluid status, including:
o pulse, blood pressure, capillary refill and jugular venous
pressure
o presence of pulmonary or peripheral oedema
o presence of postural hypotension.
 Clinical monitoring should include current status and trends in:
o NEWS
o fluid balance charts
o weight.
 Laboratory investigations should include current status and trends
in:
o full blood count
o urea, creatinine and electrolytes.
Reassessment
1.2.3 If patients are receiving IV fluids for resuscitation, reassess the patient
using the ABCDE approach (Airway, Breathing, Circulation, Disability,
Exposure), monitor their respiratory rate, pulse, blood pressure and
perfusion continuously, and measure their venous lactate levels and/or
arterial pH and base excess according to guidance on advanced life support
(Resuscitation Council [UK], 2011).
1.2.4 All patients continuing to receive IV fluids need regular monitoring.
This should initially include at least daily reassessments of clinical fluid
status, laboratory values (urea, creatinine and electrolytes) and fluid
balance charts, along with weight measurement twice weekly. Be aware
that:
 Patients receiving IV fluid therapy to address replacement or
redistribution problems may need more frequent monitoring.
 Additional monitoring of urinary sodium may be helpful in patients
with high-volume gastrointestinal losses. (Reduced urinary sodium
excretion [less than 30 mmol/l] may indicate total body sodium
depletion even if plasma sodium levels are normal. Urinary sodium
may also indicate the cause of hyponatraemia, and guide the
achievement of a negative sodium balance in patients with oedema.
However, urinary sodium values may be misleading in the presence
of renal impairment or diuretic therapy.)
 Patients on longer-term IV fluid therapy whose condition is stable
may be monitored less frequently, although decisions to reduce
monitoring frequency should be detailed in their IV fluid
management plan.
1.2.5 If patients have received IV fluids containing chloride concentrations
greater than 120 mmol/l (for example, sodium chloride 0.9%), monitor their
serum chloride concentration daily. If patients develop hyperchloraemia or
acidaemia, reassess their IV fluid prescription and assess their acid–base
status. Consider less frequent monitoring for patients who are stable.
1.2.6 Clear incidents of fluid mismanagement (for example, unnecessarily
prolonged dehydration or inadvertent fluid overload due to IV fluid therapy)
should be reported through standard critical incident reporting to
encourage improved training and practice (see Consequences of fluid
mismanagement to be reported as critical incidents).
1.2.7 If patients are transferred to a different location, reassess their fluid
status and IV fluid management plan on arrival in the new setting.
1.3 Resuscitation
1.3.1 If patients need IV fluid resuscitation, use crystalloids that contain
sodium in the range 130–154 mmol/l, with a bolus of 500 ml over less than
15 minutes. (For more information, see the Composition of commonly used
crystalloids table.)
1.3.2 Do not use tetrastarch for fluid resuscitation.
1.3.3 Consider human albumin solution 4–5% for fluid resuscitation only in
patients with severe sepsis.
1.4 Routine maintenance
1.4.1 If patients need IV fluids for routine maintenance alone, restrict the
initial prescription to:
 25–30 ml/kg/day of water and
 approximately 1 mmol/kg/day of potassium, sodium and chloride
and
 approximately 50–100 g/day of glucose to limit starvation ketosis.
(This quantity will not address patients' nutritional needs; see
Nutrition support in adults [NICE clinical guideline 32].)
For more information see IV fluid prescription for routine
maintenance over a 24-hour period.
1.4.2 For patients who are obese, adjust the IV fluid prescription to their
ideal body weight. Use lower range volumes per kg (patients rarely need
more than a total of 3 litres of fluid per day) and seek expert help if their
BMI is more than 40 kg/m2.
1.4.3 Consider prescribing less fluid (for example, 20–25 ml/kg/day fluid) for
patients who:
 are older or frail
 have renal impairment or cardiac failure
 are malnourished and at risk of refeeding syndrome (see Nutrition
support in adults [NICE clinical guideline 32]).
1.4.4 When prescribing for routine maintenance alone, consider using 25–
30 ml/kg/day sodium chloride 0.18% in 4% glucose with 27 mmol/l
potassium on day 1 (there are other regimens to achieve this). Prescribing
more than 2.5 litres per day increases the risk of hyponatraemia. These are
initial prescriptions and further prescriptions should be guided by
monitoring.
1.4.5 Consider delivering IV fluids for routine maintenance during daytime
hours to promote sleep and wellbeing.
1.5 Replacement and redistribution
1.5.1 Adjust the IV prescription (add to or subtract from maintenance
needs) to account for existing fluid and/or electrolyte deficits or excesses,
ongoing losses (see Diagram of ongoing losses) or abnormal distribution.
1.5.2 Seek expert help if patients have a complex fluid and/or electrolyte
redistribution issue or imbalance, or significant comorbidity, for example:
 gross oedema
 severe sepsis
 hyponatraemia or hypernatraemia
 renal, liver and/or cardiac impairment
 post-operative fluid retention and redistribution
 malnourished and refeeding issues (see Nutrition support in adults
[NICE clinical guideline 32]).
1.6 Training and education
1.6.1 Hospitals should establish systems to ensure that all healthcare
professionals involved in prescribing and delivering IV fluid therapy are
trained on the principles covered in this guideline, and are then formally
assessed and reassessed at regular intervals to demonstrate competence in:
 understanding the physiology of fluid and electrolyte balance in
patients with normal physiology and during illness
 assessing patients' fluid and electrolyte needs (the 5 Rs:
Resuscitation, Routine maintenance, Replacement, Redistribution
and Reassessment)
  assessing the risks, benefits and harms of IV fluids 2. Drip Infusion
 prescribing and administering IV fluids 3. Intravenous Piggyback therapy for contrast media
 monitoring the patient response 4. Intermittent venous access devices
 evaluating and documenting changes and 5. Administration of contrast media and medication
 taking appropriate action as required. VII. Venipuncture Techniques
(8 Hours)
1.6.2 Healthcare professionals should receive training and education about,
and be competent in, recognising, assessing and preventing consequences ROUTINE VENIPUNCTURE GUIDELINES
of mismanaged IV fluid therapy, including:
MATERIALS
 pulmonary oedema
 peripheral oedema 1.    Safety Needles, 22g or less
 volume depletion and shock. 2.    Butterfly needles. 21g or less
3.    Syringes
1.6.3 Hospitals should have an IV fluids lead, responsible for training, clinical 4.    Blood Collection Tubes.  The vacuum tubes are designed to draw a
governance, audit and review of IV fluid prescribing and patient outcomes. predetermined volume of blood. 
       Tubes with different additives are used for collecting blood specimens
for specific types of tests. 
3. Intravenous fluids for IV access and maintenance        The color of the rubber stopper is used to identify these additives. 
3.1. Dextrose in water solutions        See Selecting the Appropriate Collection Tube  and Specimen Container
3.2. Dextrose in saline solutions Types.
3.3. Saline solutions 5.    Tourniquets.  Latex-free tourniquets are available
3.4. Electrolyte solutions 6.    Antiseptic.  Individually packaged 70% isopropyl alcohol wipes.
33 7.    2x2 Gauze or cotton balls. 
8.    Sharps Disposal Container.  An OSHA acceptable, puncture proof
V. Patient Assessment container marked "Biohazardous".
(4 Hours) 9.    Bandages or tape
1. Organizing proper patient assessment procedure  
2. Establishing rapport with patient
3. Evaluation of patient history SAFETY
4. Observing signs and documenting symptoms
5. Monitoring and recording of vital signs 1.    Observe universal (standard) safety precautions.  Observe all applicable
6. Documenting patient assessment (pre/during venipuncture) isolation procedures.
7. Performing discharge assessment 2.    PPE's will be worn at all time.
3.    Wash hands in warm, running water with the chlorhexidine gluconate
VI. Preparation and Administration of Contrast Media and Intravenous hand washing product (approved
Solutions        by the Infection Control Committee), or if not visibly contaminated with
(4 Hours) a commercial foaming
1. Direct IV push        hand wash product before and after each patient collection.
4.    Gloves are to be worn during all phlebotomies, and changed between 5.    Position the patient with the arm extended to form a straight-line form
patient collections.  shoulder to wrist.
       Palpation of phlebotomy site may be performed without gloves
providing the skin is not broken. 6.    Do not attempt a venipuncture more than twice.  Notify your supervisor
5.    A lab coat or gown must be worn during blood collection procedures. or patient's physician if
6.    Needles and hubs are single use and are disposed of in an appropriate         unsuccessful.
'sharps' container as one unit.
       Needles are never recapped, removed, broken, or bent after 7.    Select the appropriate vein for venipuncture. 
phlebotomy procedure.        The larger median cubital, basilic and cephalic veins are most frequently
7.    Gloves are to be discarded in the appropriate container immediately used, but other may be necessary
after the phlebotomy procedure.        and will become more prominent if the patient closes his fist tightly.  At
       All other items used for the procedure must be disposed of according to no time may phlebotomists
proper biohazardous         perform venipuncture on an artery.  At no time will blood be drawn
       waste disposal policy. from the feet unless there is a specific order in the computer.
8.    Contaminated surfaces must be cleaned with freshly prepared 10%        Factors to consider in site selection:
bleach solution.  All surfaces
       are cleaned daily with bleach.             * Extensive scarring or healed burn areas should be avoided
9.    In the case of an accidental needlestick, immediately wash the area with             * Specimens should not be obtained from the arm on the same side
an antibacterial soap, express blood as a mastectomy.
       from the wound, and contact your supervisor.             * Avoid areas of hematoma.
            * If an IV is in place, samples may be obtained below but NEVER
above the IV site. 
PROCEDURE             * Do not obtain specimens from an arm having a cannula, fistula, or
vascular graft.
1.    Identify the patient.  Outpatients are called into the phlebotomy area             * Allow 10-15 minutes after a transfusion is completed before
and asked their name and date of obtaining a blood sample.
       birth.  This information must match the requisition.    Inpatients are
identified by their arm band. 8.     Apply the tourniquet 3-4 inches above the collection site. 
       If it has been removed, a nurse must install a new one before the         Never leave the tourniquet on for over 1 minute.
patient can be drawn.         If a tourniquet is used for preliminary vein selection, release it and
reapply after two minutes.
2.    Reassure the patient that the minimum amount of blood required for
testing will be drawn. 9.   Clean the puncture site by making a smooth circular pass over the site
with the 70% alcohol pad,
3.    Assemble the necessary equipment appropriate to the patient's physical        moving in an outward spiral from the zone of penetration.  Allow the
characteristics. skin to dry before proceeding. 
             Do not touch the puncture site after cleaning.
4.    Wash hands and put on gloves.
10.    Perform the venipuncture
        A.    Attach the appropriate needle to the hub by removing the plastic
cap over the small end of the container.  Label all tubes with
                needle and inserting into the hub, twisting it tight.                 patient labels, initials, date and time.
        B.    Remove plastic cap over needle and hold bevel up.
        C.    Pull the skin tight with your thumb or index finger just below the 11.    Venipuncture procedure using a syringe:
puncture site.          A.    Place a sheathed needle or butterfly on the syringe. 
        D.    Holding the needle in line with the vein, use a quick, small thrust to         B.    Remove the cap and turn the bevel up.
penetrate the skin and         C.    Pull the skin tight with your thumb or index finger just below the
                enter the vein in one smooth motion. puncture site. 
        E.    Holding the hub securely, insert the first vacutainer tube following         D.    Holding the needle in line with the vein, use a quick, small thrust to
proper order of draw into penetrate the skin and
                the large end of the hub penetrating the stopper.  Blood should                vein in one motion.
flow into the evacuated tube.          E.    Draw the desired amount of blood by pulling back slowly on the
        F.    After blood starts to flow, release the tourniquet and ask the syringe stopper.
patient to open his or her hand.         F.    Release the tourniquet.
        G.   When blood flow stops, remove the tube by holding the hub         G.    Place a gauze pad over the puncture site and quickly remove the
securely and pulling the tube off needle. 
                the needle.  If multiple tubes are needed, the proper order of draw                Immediately apply pressure.  Ask the patient to apply pressure to
to avoid cross the gauze for at least 2 minutes. 
                contamination and erroneous results is as follows:                 When bleeding stops, apply a fresh bandage, gauze or tape.
                1.     Blood culture vials or bottles, sterile tubes         H.    Transfer blood drawn into the appropriate tubes as soon as
                2.     Coagulation tube (light blue top) possible using a needleless BD
                        (Routine PT/PTT may be performed if blue top is first tube                Vacutainer Blood Transfer Device, as a delay could cause improper
collected.  It may be desirable to coagulation.
                        collect a second tube for other coagulation assays.)                Gently invert tubes containing an additive 5-8 times.
                3.     Serum tube with or without clot activator or silica gel (Red or         I.    Dispose of the syringe and needle as a unit into an appropriate
Gold) sharps container.
                4.     Heparin tube (Green top)  
                5.     EDTA (Lavender top)
                6.     Glycolytic inhibitor (Gray top) 12.    Infant/Child Phlebotomy
                     A.    Confirm the patient's identification
       H.    Each coagulation tube (light blue top) should be gently inverted 4         B.    Secure patient to Papoose apparatus for stabilization if child is
times after being removed from the hub.  Red and gold tops should be unable to sit upright
inverted 5 times.  All other tubes containing an additive should be gently                on their own.
inverted 8-10 times.  DO NOT SHAKE OR MIX VIGOROUSLY.         C.    Assemble the required supplies
                  D.    Select the collection site and proceed as routine phlebotomy.  If
         I.    Place a gauze pad over the puncture site and remove the needle.  the child is old enough,
                Immediately apply slight pressure.  Ask the patient to apply                collect blood as in an adult. 
pressure for at least 2 minutes. 
                When bleeding stops, apply a fresh bandage, gauze or tape. SPECIAL NOTE WHEN USING BUTTERFLY COLLECTION DEVICE: When
        J.     Properly dispose of hub with needle attached  into a sharps coagulation  tube (light blue top)
 will be the first tube collected, it is MANDATORY to collect a DISCARD light 7.       Participating in the IRB to have a voice in encouraging research studies
blue top first to remove to be conservative in blood
 the air from the tubing.  A second light blue top can then be collected collection.
appropriately.  Failure to
collect the discard tube may result in specimen being rejected due to 8.       Communicating with nurse managers and staff education to improve
inappropriate volume. blood draw techniques to
  minimize hemolyzed, clotted  and unsatisfactory specimens to
prevent redraws.
CLINICAL LABORATORY BLOOD DRAW MINIMIZATION
9.       Assuring the competence and accuracy of phlebotomists by prompt
 1.      Increasing the number of point of care glucose and electrolyte testing communications when
devices which use a specimen collection problems occur and providing solutions and
         fingerstick sample to perform test instead of drawing a whole tube of corrective action when needed.
blood to send to the lab.
10.      Saving blood specimens in the proper environment for the maximum
2.       Doing a thorough search in our LIS to see if blood can be used from an usage time span  to increase
earlier draw whenever opportunities for not having to redraw a specimen.
there is an add-on test requested to prevent patient from being
drawn again.  

3.       The Clinical Lab coordinated an intradisciplinary committee to reduce TROUBLESHOOTING HINTS FOR BLOOD COLLECTION
mislabeled and unlabeled
specimens to prevent patient redraws . The lab audits and sends out If a blood sample is not attainable:   
notification for corrective
action in cases of non-compliance.  Reposition the needle. 
 Ensure that the collection tube is completely pushed onto the back
4.       Designing our LIS system to identify minimum volumes of blood to be of the needle in the hub.
drawn for all tests and  Use another tube as vacuum may have been lost.
print out the appropriate number of labels to match the different  Loosen the tourniquet.
types of blood tubes to be drawn.  Probing is not recommended.  In most cases, another puncture in a
site below the first site is advised.
5.       Purchasing testing equipment in the nursery laboratory which uses a  A patient should never be stuck more than twice unsuccessfully by a
lesser volume of blood than phlebotomist.
previous equipment. The Supervisor should be called to assess the patient.

6.       Participating in Nursery quality control meetings weekly which address

methods of improvement VIII. Adverse Reaction to IV Contrast Media and Medication
for reducing the volume of blood collection. ADVERSE RADIOPAQUE CONTRAST REACTIONS
 Diagnostic procedures, which involve the use of radiopaque
-is an undesired and sometimes harmful response to a medication.
contrast agents, should be carried out under the direction of medical
It is estimated that between 1 and 2 million adverse drug reactions occur
professionals with prerequisite training and thorough knowledge of the
yearly in the United States with occurrence estimations as high as 30% for
appropriate protocol for the procedure to be performed. All orders must be
all hospitalized patients.
closely checked and questioned when unclear or if they seem to be
Millions of people are administered radiographic contrast agents
inappropriate. Radiology professionals are mandated to act as a patient
annually. Radiographic contrast agents are used to better delineate
advocate. Simply administering contrast agents “because the doctor
anatomical structures and areas that are otherwise penetrated by ionizing
ordered it that way” or “because it is the protocol” does not serve as a legal
radiation and to determine function or physiological make-up. Many factors
defense if the patient experiences a negative outcome. The radiology
contribute to the way the body reacts to drugs, some are within the control
professional is responsible for being knowledgeable regarding the
of the medical professionals, and others are not. One factor is the aging
appropriate dosage, integrity of the contrast medium, and indications for
process, which changes the way the body absorbs, metabolizes, and
the radiopaque agent administered.
excretes drugs. Another factor involves certain disease processes that can
predispose patients to a greater risk such as: allergies, cardiac disease
Drugs Routinely Administered During Radiology Procedures:
(unstable angina, congestive heart failure, pulmonary hypertension, and
Diatrizoate Meglumine: Aqueous solution for pre-enteral use. This
arteriosclerosis), thromboembolic diseases, pheochromocytoma, colon
radiopaque agent is indicated in excretion
obstruction/perforation/fistula, diabetes, sickle cell anemia, multiple
urography, cerebral/peripheral
myeloma, renal dysfunction and dehydration.
arteriography, venography, operative T-
tube or percutaneous transhepatic
Radiopaque Contrast Agents Administration – The Ground Rules
cholangiography, splenoportography,
arthrography, discography and
computerized tomography as an
enhancement agent.
Diatrizoate Sodium: Palatable water-soluble iodinated contrast Barium Sulfate: Insoluble material which, because of its
medium for oral or rectal administration. density, provides a positive contrast
Administration of this medium is indicated medium. Barium sulfate is an inert
for radiographic segments of the radiopaque material that is not absorbed or
gastrointestinal tract (esophagus, stomach, metabolized and is eliminated intact from
proximal small intestine and colon). This the body in a manner similar to other non-
agent may also be used as an adjunct to absorbed inorganic materials. Barium
contrast enhancement in computed Sulfate, based on it consistency, may be
tomography of the torso (body imaging). administered as an oral or rectal
radiopaque medium for use in imaging the
Iopamidol: Stable aqueous, non-pyrogenic solutions for intestinal tract.
intravascular administration. Iopamidol
injections may be used for angiography Glucagon: Polypeptide hormone identical to human
throughout the cardiovascular system glucagon that increases blood glucose and
including cerebral and peripheral, coronary relaxes smooth muscle of the
arteriography, ventriculography, pediatric gastrointestinal tract. Administered through
angiocardiography, selective visceral a parenteral route, Glucagon relaxes the
arteriography, aortography, peripheral smooth muscle of the stomach, duodenum,
venography and adult/pediatric intravenous small bowel, and colon.
excretory urography. Also indicated for use
of adult and pediatric contrast Gadopentetate Dimeglumine:
enhancement of computerized tomography
of head and body imaging.
 Injectable contrast medium for magnetic What Actually Produces the Adverse Drug Reactions that are Seen
Clinically?
resonance imaging (MRI). Gadopentetate
Adverse drug reactions in a person’s body can occur from an
Dimeglumine is to be administered by
immunologic process or through non-immunologic responses. The
intravenous injection. It is a paramagnetic
immunologic reaction involves antibodies that are normally produced by the
agent and as such, it develops a magnetic
body. In general terms, the human body has a group of cells that belong to
moment when placed in a magnetic field.
the immune system. The basic cells are labeled T-cells and B-cells.
Therefore, the indication for use is in MRI to
The T-cells are further broken down into T-4 cells and T-8 cells. The
provide contrast enhancement in those
T-4 cell (which usually accounts for about 70% of the T-cell population) is
intracranial lesions with abnormal
called the helper-inducer cell and is the “captain” of the ship. This cell is
vascularity, lesions causing abnormality in
responsible for identifying substances that do not normally belong in the
the blood brain barrier or to facilitate
body, such as viruses, bacteria, pollens, and drugs or medications, etc.
visualization of lesions in the spine and
When the T-4 cell identifies one of these substances, it “activates” the
associated tissues.
immune system by informing the T-8 cells and the B-cells. The B-cells
actually produce the antibodies or immunoglobulins that are found in our
Gadoteridal: Nonionic contrast medium for Magnetic
bodies. The primary antibodies that are formed are IgM, IgG, IgA, and IgE.
Resonance Imaging. This MRI contrast
The T-8 cells (which account for the remaining 30% of the T-cell population)
agent is also paramagnetic. Using an
are called the killer-suppressor cells.
injection of Gadoteridal provides contrast
enhancement of the brain, spine, and
surrounding tissues resulting in improved
visualization of lesions with abnormal
vascularity, lesions causing abnormality in
the blood brain barrier or to facilitate
visualization of central nervous system
lesions including but not limited to tumors.
 The best way to explain this system is by using an example. Lets
assume a cold virus infects you. The T-4 cell identifies this virus and
determines that it does not belong in your body. In the meantime, this virus
is replicating and causing cells to die, which releases substances that
damage the area and produce the symptoms that are seen in the sites that
are infected, i.e. the nose, throat, and bronchial tree when using the
common cold as an example. The T-4 cells, however, have activated the T-8
cells to kill the virus and have turned on the B-cells to produce antibodies
against it. In a few days, your body has enough defenses to ultimate kill the
virus and you eventually get better. Not to belabor this point, however, the
human immunodeficiency virus (HIV) primarily infects T-4 cells. As you can
see from this discussion, people infected with HIV develop numerous
problems because the “captain” of the immune system is rendered
dysfunctional.
As stated in the preceding paragraph, as cells die, substances are
released into the body that produce further reactions and symptoms. Some
of these substances include histamine, cytokines, platelet-activating factor,
prostaglandins, tumor necrosis factor, and enzymes. When a drug produces
a typical allergic reaction through the immune system, it usually involves IgE
or IgA antibodies. These antibodies may be found on the surface of
sensitized cells and when exposed to the drug, will result in the release of
these chemicals.
IgE-dependent drug reactions can be immediate or accelerated.
The “immediate” reactions usually occur within minutes and can include
itching (pruritus), rashes, nausea, vomiting, laryngeal edema,
bronchospasm, hypotension, shock (anaphylaxis, described in more detail
below) and even death. “Accelerated” reactions occur hours to days after
the drug is administered and usually involve urticaria (hives) and
occasionally laryngeal edema.
One other type of immune related drug reaction is the immune-
complex or serum sickness process. This is rare and is primarily seen with
drugs that remain in the body for prolonged periods or drugs that are taken
by an individual over a period of time. This usually involves IgG antibodies.
The symptoms of this reaction are fever, arthritis, nephritis, urticaria,
edema, and neuritis. Drugs that have been associated with serum sickness
are the penicillins, the sulfonamides, cholecystographic dyes, thiouracils,
and phenytoin.
Drug reactions can also produce a response through non-
immunologic means. Some of the ways this can occur are:
 By direct release of irritating substances from certain cells in the
body.
 By interaction with other drugs.
 Through exacerbating a pre-existing condition in the person.
 Through cumulative effects and overdosage.
 Non-immunologic drug reactions are actually responsible for the
majority of drug reactions that occur. Some drugs may cause the direct
release of histamine, cytokines, and enzymes from cells without the help of
antibodies. This is another pathway for the development of anaphylaxis.
This is also a common cause for urticaria or hives. Drugs that commonly
produce hives include narcotics, radiocontrast media, and some antibiotics.
Drugs may also cause direct reactions by interfering with certain enzyme
pathways, either through stimulation or inhibition.
The common ways in which drugs can interact with each other is by
competing for the same binding sites on certain cells found in various
organs (which results in an overall decrease in function by the drug), by
stimulating enzymes that metabolize another drug more quickly, or by
inhibiting how quickly the kidneys excrete a drug.
Some drugs may exacerbate a pre-existing condition in a patient.
For instance, medications used for one function may also produce another
response as a side effect. For example, some decongestants can increase a
person’s blood pressure, which may not be good for a person with
cardiovascular disease or diabetes. In addition, since drugs can produce an
immunologic response in some people, individuals with immune related
diseases, such as Lupus or Rheumatoid Arthritis, should also be cautious.
Finally, some medications can have an accumulative effect. Again,
this is uncommon for radiocontrast material and usually requires prolonged
use or multiple doses. Some examples for this type of reaction include
some chemotherapy drugs or prolonged usage and exposure to mercury,
silver, or gold.
Adverse Reactions
The possibility of a reaction (mild to severe) should always be
considered. Patients may not react by having all of the symptoms listed
below. The degree of severity and type of onset is patient dependent.
Patients with known or questionable histories of sensitivity to radiopaque
contrast agents may be given a pre-medication to minimize the risk of
reaction. The most common pre-treatment regiments employ the use of
either a corticosteroid (such as prednisone) or antihistamines (such as
diphenhydramine, i.e. Benadryl). When contrast agents, especially
diatrizoate meglumine or diatrizoate sodium are administered (organically
bound iodine), the crash cart should be on hand. To minimize the risk of
acute renal failure (ARF) careful attention should be paid to the patient’s
hydration status, before, during and after the diagnostic procedure.
Type of Adverse Reaction Symptoms:
Cardiovascular Reactions can be varied. Peripheral vasodilatation can
occur, which decreases systemic blood pressure (hypotension), which in
turn causes a reflex tachycardia (rapid heart rate or pulse). Sometimes
vasoconstriction can occur resulting in an increase in blood pressure
(hypertension) that may result in a slowing of the heart rate (bradycardia).
The heart itself can be directly affected producing arrhythmias (i.e.
ventricular fibrillation), myocardial ischemia and angina pectoris (chest
pain), and even complete circulatory collapse. If a bradycardia occurs, this
can result in fainting or blacking out. Because many agents are administered
intravenously, sometimes there can be direct injury to the blood vessel
resulting in thrombophlebitis.
Nervous System Reactions can present as pain, a burning sensation, or a
tingling in an extremity. The vagus nerve can also sometimes be stimulated
producing a vasovagal reaction with bradycardia and syncope.
Digestive System Reactions involve nausea, vomiting, and anorexia.
Respiratory Tract Reactions include bronchial constriction, which results in
tachypnea (rapid breathing) and dyspnea (shortness of breath). Severe
cases can result in pulmonary edema.
Skin Reactions are common and include rashes, urticaria (hives), pruritus
(itching), and flushing (redness of the skin).
Special Senses can be altered producing taste alterations, nasal congestion,
visual disturbances, a feeling of warmth and or a feeling of being cold.
Other Body Reactions may include hot flashes, headache, fever, chills, and
excessive sweating.
Anaphylactic Reactions
Anaphylaxis is a severe hypersensitivity reaction to a causative
agent or agents. Anaphylactic reactions cause large quantities of histamine
to be released, which in turn causes an increase in capillary permeability
and widespread dilation of arterioles and capillaries. Another organ that can
be affected is the respiratory system resulting in severe shortness of breath.
Other symptoms can include facial and/or laryngeal edema, fainting, itching,
and urticaria (hives). One of the treatments for this disorder is epinephrine,
which constricts the dilated blood vessels and helps to dilate the bronchial
tree. Some of the other symptoms can be treated with an antihistamine
such as Benadryl.
The “5” Rights
Be sure to have the “right” (1) patient, (2) medication, (3) route, (4)
dosage, and (5) monitoring. If that is followed, what is left to worry about?
The radiographer should (1) identify allergy histories and make a list of
drugs or foods that the patient is allergic to with a description of the
“reaction” that occurred; (2) identify incompatibilities – for example:
patients taking glucaphage (a prescription drug for diabetic patients) who
are scheduled for a radiographic procedure that requires administration of
either glucagon or diatrizoate meglumine or diatrizoate sodium should
consult with a physician before administering; (3) correctly prepare the
agent to be administered; (4) perform adequate monitoring after the drug is
administered; and (5) educate the patient regarding the administration of
drugs for the procedure(s) they are about to undergo.
Reminders
 Carefully look at drug labels and be mindful of expiration dates.
  Use prescribed directions for making solutions.
 Avoid contamination of sterile agents.
 Always remember to confirm IV functioning or tube placement
before administering agents.
 Observe the recommended administration dose and/or injection
rates.

Remember that every administration of a radiopaque contrast agent has the

potential to cause an anaphylactic reaction, even if the patient has received
contrast in the past with no reported adverse effect.

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Baer, Charold L., Bradley R. Williams. Clinical Pharmacology and Nursing. 3rd
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Estes, Mary Ellen Zator. Health Assessment and Physical Examination. USA:
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Josephson, Dianne L. Intravenous Infusion Therapy for Nurses: Principle and
Practice. USA: Delmar Learning, 2004.
Kee, Joyce LeFever, Evelyn R. Hayes. Pharmacology, A Nursing Process
Approach. 4th ed. Philippines: Elsevier Science, 2005.
Tortorici, Marianne. Administration of Imaging Pharmaceuticals.
Philadelphia: W. B. Saunders, 1996.