DRUG

CATEGORIES
AND
CLASSIFICATIO
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Contrast
media
Agents that are introduced to the
body with higher or lower atomic
number than the body part
examined.
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 Uses of contrast media
✗ contrast media to aid in the visualization of a body part or
body system.
✗ Contrast media are required to visualize areas of the body
when the organ or system of interest is too similar to the
surrounding area.

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✗ to increase the visibility of body cavities, organs, and the
vascular system in diagnostic imaging, fluoroscopy and other

imaging modalities such as CT and MRI.

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Two types of contrast
media
✗ Positive ✗ Negative
Contrast Contrast
Media Media

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Negative contrast
media
✗ Agents that have low atomic number.
✗ Gases of low density
✗ Appears Radiolucent
✗ Examples:
✗ Air
✗ Oxygen
✗ Carbon Dioxide

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Positive contrast
media
✗ Agents that have high atomic number
✗ It appears moreradiopaque than the surrounding tissue.
✗ 2 Types of Positive CM
✗ Barium-Sulphate
✗ Iodinated Contrast Media
■ Ionic
■ Non-ionic
✗ Gadolinium

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 Barium sulphate BaSO4

✗ Atomic Number of 56
✗ is the most common type of contrast used in imaging the
GI system.

✗ Barium is a metal and does not dissolve; therefore, it is

suspended in solution.

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✗ The metallic component of barium makes it an ideal
substance for use as a contrast agent.

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Bariu sulphatBaSO4
m e

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Iodinated contrast media
✗ Iodine, with an atomic number of 53, is able to absorb
the x-ray photons, thus allowing the area of interest to
be seen on the radiographic image as a white area.

✗ used in the examination of the GI tract, kidneys,

gallbladder, pancreas, heart, brain, uterus, spinal
column, arteries, veins and joints

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 IONIC AND NON-IONIC CONTRAST MEDIA
✗ Radiodensity in body tissues of the contrast medium is
related to the percentage of iodine in the contrast
medium
✗ All positive contrast media are made up of
✗ a cation (a positive charge) {either sodiu or meglumine
compound.

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✗ an anion (a negative charge)

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2 commonly used iodinated
substances
✗ Iothalamate
✗ Diatrizoate

✗ Each contains
✗ Methylglucamine(meglumine)Salt
✗ Sodium Salt

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✗ Meglumine compounds
are less toxic but more
viscous than sodium
compounds.

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Ionic contrast
media
✗ Ionic
positively charged
consist of the negatively charged and the

✗ Used components of the

are for example
■ diatrizoate,
■ iodamide,
■ iothalamate or
■ metrizoate
the
■ sodium or meglumine
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✗ The osmotic pressure depends on the number of
particles in solution.

✗ Osmolarity
■ refersto the number of particles of solute per
liter of solution,

✗ Osmolality
■ refers to the number of particles of solute per
kilogram of solvent.
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✗ Ionic contrast agents have a greater osmolarity;
double that of nonionic contrast agents due to
delivering more iodine atoms per molecule.
✗ Ionic contrast agents were developed first and
are still in use depending on the examination.
✗ Iodine based contrast media are water soluble and
as harmless as possible to the body.

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✗ However, ionic agents have more side effects
compared to nonionic contrast agents due to
their high osmolarity.
Non-ionic iodinated contrast media
✗ are a group of contrast media that do not dissociate into
charged particles.

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✗ Many of the side effects of contrast agents are due to the
injection of a solution with high osmolality compared to
blood.
✗ Nonionic contrast agents have a low osmolality and tend to
have less toxicity. Due to their lower neurotoxicity, nonionic
contrast agents can also be used for myelography.

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 ✗ The approved agent,
iodixanol, is iso-osmolarto blood,
which makes it preferable for
examinations of the central nervous
system and cardiovascular studies
.

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 gadolinium
✗ is a chemical element with the symbol Gd and atomic
number 64.
✗ Gadolinium below its Curie point of 20 °C (68 °F) is
ferromagnetic, with an attraction to a magnetic field
higher than that of nickel.
✗ Above this temperature it is the most paramagnetic
element. It is found in nature only in an oxidized form.

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✗ When separated, it usually has impurities of the other
rare-earths because of their similar chemical properties.

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Factors to consider in selecting contrast
agents
✗ Ability to mix with other fluids.
✗ Viscosity (lower viscosity = faster injection rate or flow
rate)
✗ Ionic strength
✗ Persistence in the body
✗ Osmolality
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✗ Iodine content / concentration (higher iodine content =
more radiopaque)
✗ Potential for toxicity
Pharmacokinetic
s of contrast
media
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Pharmacokinetics of
Contrast Media
✗ The chemical structures of the-ionic
nonand ionic
contrastmedia are significantly different.

✗ Ionic contrast media are salts of iodinated benzoic acid

derivatives that were depended upon for radiographic
and CT imaging in the past.
✗ As salts, the ionic contrast media consist of a positively
charged cation and a negatively charge anion.

✗ They are also strong acids and are completely

disassociated (ionized) in solution.

✗ For every three iodine atoms in a contrast solution,

there are two particles for osmolality, one anion and one

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 cation. These are known as high-osmolar contrast media
(HOCM).
✗ It is the iodine in contrast media that provides the
contrast (density difference) between the organ and
the surrounding tissues.

✗ Advances in iodinated radiopaque contrast media

resulted when research was focused on the ratio

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 between the number of iodine atoms present and the
number of particles in solution.
✗ The chemical makeup of ionic and non-ionic contrast
differs in the number of particles in solution and
not the number of iodine compounds.

✗ It was discovered that if the cation was removed

there was no diagnostic information lost since the

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 cation did not contain any of the image producing
iodine.
✗ The cation was replaced with a compound such as glucose
that does not disassociate in solution.
✗ The result was a contrast agent that still contained the
three iodine atoms for contrast and only one particle for
osmolality.

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✗ The lower osmolality factor defines the group of
contrasts known as non-ionic contrasts, or low-osmolar
contrast media (LOCM).

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✗ With the salt compound removed, the patient was
less likely to suffer adverse reactions and was
more comfortable during the procedure.

✗ Whenpossible, these LOCM are chosen by the

physician as they have a wider margin of safety.

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 osmolalit
The weight of the ion
y
✗ The osmolality (the weight of the ion) of a contrast
agent is a significant factor considered when side
effects may cause severe complications for the
patient.

✗ Conventional ionic media (HOCM) are significantly

hyperosmotic to body fluids such as blood because
they disassociate into separate ions in solution.

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✗ This can cause adverse effects that vary from
cardiac events, vein cramping and pain to abnormal
fluid retention.

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✗ The osmolality of -ionic
non contrast agents is closer to
that human plasma than ionic agents at similar iodine
concentration.

✗ Imaging departments differ in choice of LOCM for all

patients versus selective use of LOCM only on patients
at increased risk for adverse reactions.

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LOCM are chosen for the following types
of patients:

1. Patients with a history of previous adverse

reaction to contrast media.
2. Patients with asthmatic conditions
3. Patients with known cardiac conditions
4. Patients who are severely debilitated
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5. Patients at high risk for contrast extravasation
6. Patients for whom the physician feels there is an
indication for its use.

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Patient

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Reactions
to Contrast
Media and

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Media and Radiographer’s
Response

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✗ Reactions to contrast media occur most often
when the medium is administered
intravenously or intra-arterially.

✗ Expected side effects must be explained to the

patient before the procedure begins to
alleviate anxiety.

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✗ These include a feeling of warmth and flushing and a
metallic taste in the mouth. These effects are usually
due to the speed with which the contrast is injected and
will pass within a few minutes.

✗ Although these side effects are normal and not a true

contrast reaction leading to a life-threatening situation,
they may cause the patient to vomit, which will delay the
start of the procedure and thus the quality of the exam
due to contrast elimination.
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✗ Adverse reactions to contrast media are
rare, but they do happen.
✗ Reactions
are not predictable and may
be life
-threatening.

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✗ HOCM are most frequently associated with adverse
events. These reactions range from mild to severe.

✗ LOCMhave a much lower reaction rate by four to five

times. Skill in detecting and dealing with potential
adverse symptoms makes the difference in patient
outcomes.

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Reducing patient’s anxiety
1. Assessment of the patient’s understanding of the
procedure.
2. Informing the patient in detail (but in a manner that is
understandable) concerning how the examination will
proceed.
3. Explanation of the expected side effects and
assurance that these are not unusual.

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4. Allowing the patient to express feelings of anxiety and
obtaining patient feedback to ascertain his complete
understanding of the procedure.
Patient Assessment prior to
Administration of
Contrast Medium
✗ 1. Patient’s age
✗ 2. History of impaired hepatic function (liver disease)

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✗ 3. History of impaired renal function (kidney disease)
✗ 4. History of allergic or anaphylactic reactions
✗ 5. History of thyroid disease

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✗ 6. Last menstrual period and possible
pregnancy
✗ 7. Nursing mother
✗ 8. Sensitivity to aspirin
✗ 9. History of diabetes mellitus
✗ 10 . History of sickle cell disease
✗ 11 . History of hypertension
✗ 12 . History of pheochromocytoma

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✗ 13. History of seizures
✗ 14. Medication history
✗ 15. History of previous reactions to
medications or
✗ contrast agents
✗ 16. Allergy to seafood

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✗ The patient’s emotional status should be noted on the
form and signed by the radiographer.
✗ During any injection of contrast medium, the patient
must be monitored for abnormal responses or
reactions.
✗ The emergency cart, equipment, and medical response
personnel must be immediately available. The
radiographer must be alert for extravasation of the
contrast agent.

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✗ If it should occur, he must immediately stop the IV
and apply warm compresses to the area to ✗ reduce
pain and tissue damage.

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Clinical manefestation of side
effects
✗ Feeling of flushing or warmth
✗ Nausea and/or vomiting ✗ Headache
✗ Pain at the injection site ✗ Altered taste, may be metallic

Radiographer’s
response
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1. Slow the rate of the contrast infusion.
2. Observe the patient closely and offer reassurance.
Clinical manefestation of
vasovagal reaction
✗ Pallor
✗ Cold sweats
✗ Rapid pulse
✗ Syncope or complaint of feeling faint
✗ Bradycardia ✗ Hypotension

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 Radiographer’s response
✗ 1. Stop the infusion of contrast medium.
✗ 2. Place the patient in flat or Trendelenburg position.
✗ 3. Notify the radiologist.
✗ 4. Remain with the patient and offer reassurance.
Clinical of Mild Adverse
Manifestations Reaction
✗ Nausea, vomiting

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✗ Cough ✗ 1. Stop the infusion and notify
✗ Feeling of warmth the radiologist or radiology
✗ Headache ✗ Dizziness ✗ nurse.
Shaking ✗ Itching ✗ ✗ 2. Remain with the patient and
Pallor offer reassurance.
✗ 3. Prepare to assist in the
Radiographer administration of an
antihistamine or subcutaneous
’s response epinephrine.

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 Clinical Manifestations of MODERATE
Adverse Reaction
✗ Tachycardia or bradycardia
✗ Hypertension or hypotension
✗ Dyspnea
✗ Bronchospasm or wheezing
✗ Patient complains of feeling of throat closing (laryngeal
edema)

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 Radiographer’s response
1. Stop the infusion.
2. Notify the radiologist and the radiology nurse.
3. Call for the emergency team if symptoms progress rapidly.
4. Remain with the patient and offer reassurance.
5. Prepare to administer oxygen and intravenous medications.
6. If the patient is in respiratory distress, place him in semi-
Fowler’s position.
7. Position patient who is vomiting in a position to prevent
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aspiration. 67
Clinical Manifestations
SEVERE ANAPHYLACTIC
of Reaction
✗ Dyspnea related to laryngeal edema
✗ Hypotension
✗ Seizures
✗ Cardiac arrhythmia
✗ Lack of patient response
✗ Cardiac arrest

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 Radiographer’s response
1. Call for emergency response team (Code Blue).
2. Notify the radiologist and radiology nurse.
3. Prepare to use AED (automated external
defibrillator).
4. Prepare to administer oxygen and intravenous
medications.
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Legal Aspect of
IV
Contrast Media
and
Medication
 Adm ini
stration
✗ International Society of Radiographers
and Radiological Technologists’ Position

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 Statement on the supply and
administration of contrast agents
– including oral and intravascular
administration to patients by
Radiographers, Medical Radiation
Technologist, Radiologic Technologist
and Radiation Therapists
The ISRRT considers the administration of oral and
intravenous contrast agents within the scope of
practice for radiographers/medical radiation
technologists and radiation therapists subject to
their demonstration of appropriate educational
preparation leading to clinical competency to carry
out the task as trained and where the administration
of oral and intravenous contrast is permissible by
regulation of law.

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Radiographers, Medical Radiation Technologists and
Radiation Therapists following their training will obtain
a thorough understanding and
knowledge of the identification, preparation,
calculation, documentation, administration and
patient monitoring related to the knowledge of
indications, contraindications, warnings,
precautions, proper use and adverse reactions for the
safe use of contrast agents.
Radiographers, Medical Radiation Technologists and
Radiation Therapists will also be competent following
their education and training to
competently observe patients for possible
complications and adverse reactions following the
administration of contrast agents and
respond appropriately with agreed interventions
to such complications in conjunction with other
available staff including a physician where
regulation or law dictate.
All healthcare facility policies are developed to
ensure that safety and quality is obtained to
include both independent practices as well as
hospital settings.
The ISRRT Board promotes the scope of practice for the
administration of oral and intravenous
contrast agents by Radiographers, Medical
Radiation Technologists and Radiation
Therapists in the delivery of safe, cost-effective and high
quality diagnostic imaging services.
RESPONSIBILIT
IES
• 1.The Chief of Staff assures overall compliance
with every procedure.

• 2. The Imaging Service Chief is responsible for

ensuring that all contrast protocols are approved
by the Pharmacy and Therapeutics Committee,
medications are stored in secure locations and
adverse contrast events are reviewed and trends
 identified and corrective action taken by the
Imaging Quality Improvement Committee.
• 3. The in-house Radiologist/Radiology Resident, whose scope
of practice agreement includes the ability to obtain
informed consent and who participates substantially in the
procedure of contrast administration is responsible for:

• Approving the use of contrast for each patient individually, typically

in the form of specifying one or more standard imaging protocols.
• The supervision of the contrast injection during regular business
hours.

• Obtaining medical consent for high risk patients during regular

business hours.

• Following all the procedures.

• 4. The ordering provider/Resident is
responsiblefor:
• Orderingany necessary premedication for
patients with previous reactions to
contrast.
• Orderingall pre-procedure laboratory
tests needed prior to contrast
administration.
• 5. The Radiologic Technologist is responsible for:
 • Reviewing the procedure, risks,
benefits and alternatives with
patients who receive IV contrast
using an approved educational
script.
• Responsible for identifying the designated line
for IV contrast administration in conjunction
 with nursing and following the intended line to
the site of insertion prior to IV contrast
injection.

• The technologist will sign the Patient

Questionnaire which will indicate that the selected
line is appropriately labelled line and will serve as
the intended injection line. If there is no line
appropriate for IV contrast, the technologist will
initiate a new IV
• Administering intravenous contrast according
to protocol and monitoring the patient for
evidence of extravasation or adverse
reactions.
• Complying with all policies and procedures
relating to the administration of contrast
media and disclosure of adverse events.
• 6. The nursing executive is responsible for
ensuring overall compliance of nursing
personnel with procedures relating to the
administration of contrast media.
• 7. Pharmacy service is responsible for the
ordering, procurement and delivery of contrast
agents to the specific radiology areas.
Pharmacy service is also responsible for the
yearly review of the contrast agents utilized in
conjunction with Radiology service. Pharmacy
will routinely audit all areas in which contrast
agents are stored.
Documentation of
Administrati
Contrast
on
Informed Consent for IV Contrast Media
Iodinated Contrast – The risks and benefits of Iodinated
contrast agents will be discussed by the technologist, physician
or registered nurse who reviews the patient questionnaire.
Another consent for iodinated contrast will be required only
for patients with Scr equal to or above 2.0 and when the

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volume of contrast exceed 3.7 times creatinine clearance
within a 24-hour time frame.
Informed Consent for IV Contrast Media
GADOLINIUM Contrast –The risks and benefits of the
MRI contrast agents will be discussed by the technologist,
physician or registered nurse who reviews the MRI
Questionnaire. Another consent for MRI contrast will be

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required only for patients who have a previous history of
reaction to gadolinium contrast media, patients who are
pregnant and patients with Egfr < 30 mL/min.
Administration and Documentation of
Contrast Agents
✗ 1. Physicians in the Radiology service are authorized
per to administer contrast after approval of the

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Patient Questionnaire and contrast review. A
radiologic technologist who has been trained by
Radiology Service or who possesses
license/certification for contrast administration by
the State may administer contrast after approval of
the Patient Questionnaire and contrast review by a
radiologist.

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✗ 2. Technologists may start peripheral intravenous
lines for the purpose of contrast administration if
they have undertaken training to do so, or have
graduated from an American Registry of Radiologic
Technologist (ARRT) recognized program that
includes intravenous access in the curriculum and
have demonstrated competency by a period of
proctoring.

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✗ The Patient Questionnaire will include the patient’s
name, date of procedure, types of procedure,
medical record number, the name of the personnel
administering the contrast media, type of contrast
media and amount, dose, and rate, lot number as well
as complications that occur and any required followup.
The Patient Questionnaire will be scanned into the
procedure imaging file (PACS).

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Thanks!
Any questions?
You can find me at:
✗ @janineclairedcbuco
✗ jcbuco.cort@gmail.com

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