Module 1:

Contrast Media
Abby Louisse Pearl A. Ventura, RRT
History
▪ Walter Dandy (1918) – did injections of air to study the cerebral ventricles of
children with hydrocephalus
▪ Later, carbon dioxide, nitrous oxide, and oxygen came into use
▪ 1896 – lead subacetate was used to study the digestive system of the guinea pig
▪ Walter Cannon (1896) – began a series of experiments to study the digestive
system using bismuth subnitrate
▪ Thorotrast – incorporated with thorium, proved to be radioactive
▪ 1910 - inert and insoluble compound barium sulfate began to appear in the
medical literature
▪ Egas Moniz (1927) – introduced water-soluble iodinated contrast media injected
▪ Sodium iodide is injected into the cerebrovascular circulation by way of the
carotid arteries
▪ 1930s – chemical methods improved
▪ 1950s - use of three iodine atoms per carrier molecule
Factors that affect the degree of radiographic density
differences:
1. Absorption characteristics of the tissues that comprise the
anatomic part
2. Technical factors used
3. Characteristics of the image receptor
4. Automatic image processing
5. Use of contrast media
Purpose of Contrast Media
Contrast media – diagnostic agents that are instilled into
body orifices or injected into the vascular system, joints,
and ducts to enhance subject contrast in anatomic areas
where low subject contrast exists.
❑ Purpose: to enhance contrast
General Types of Contrast Agents
1. Negative (Radiolucent)
➢ X-ray photons are easily transmitted or scattered through
radiolucent contrast media.
➢ Relatively lucent to x-rays.
➢ Anatomic areas appear dark
➢ Composed of elements with low atomic numbers.
2. Positive (Radiopaque)
➢ X-ray photons are absorbed by radiopaque contrast media
because these media are opaque to x-rays.
➢ Anatomic areas appear light/white
➢ Composed of elements with high atomic numbers.
❑ In some instances, negative and positive agents are used together.
Specialty Contrast Agents
▪ MRI studies – gadolinium diethylenetriaminepentaacetic
acid (gadolinium-DTP
▪ Ultrasound contrast agents – gas-filled microbubbles that
affect the sound wave to enhance ultrasound contrast
 Negative
Contrast Media
Physical Properties
▪ Low–atomic-number elements
▪ Administered as gas (air) or gas-producing tablets, crystals, or
soda water (carbon dioxide)
▪ Because cells absorb oxygen quickly, this gas is rarely used
alone as a contrast agent.
Specific Procedures
• Laryngopharyngography
• Used in combination with radiopaque media to outline the
lumens of, or spaces within, body structures
 Specific Procedures
Area Contrast Agent Method of Patient Px Instructions &
Administration Preparations Care during
Procedure
Stomach BaSO4 Oral NPO after midnight Px should not belch
CO2 as tablets, before examination after CO2 is given
crystals or soda so the lumen of the
water stomach can be
seen
Large intestine BaSO4 Rectal Fluid diet before Provide supportive
Air examination, NPO communication
after midnight &
cleansing enema
before examination
Arthrography Water-soluble Injection into joint None Provide supportive
iodine media space communication
air
Adverse Reactions
• Minimal complication but air may cause emboli
• Small air masses can enter the circulatory system and become
lodged in blood vessels, causing pain and loss of oxygen to the
area.
 Positive
Contrast Media
Physical Properties
• Barium sulfate – 56 Z
• Inert powder composed of crystals that is used for examining
the digestive system
• BaSO4: indicates a ratio of one atom of barium to one atom of
sulfur to four atoms of oxygen
• Must be mixed or shaken into a suspension in water
• Flocculation – when the powder tends to clump and come out
of suspension
• Sodium carbonate or sodium citrate – stabilizing agents to
prevent flocculation
• Must be concentrated
Physical Properties
• Small intestine – oral formulations of barium
sulfate & methylcellulose, a nondigestible
starch
• Lower GI studies - barium sulfate be mixed
with cold tap water
• Colon – barium sulfate suspensions
• Addition of 2 teaspoons of table salt
per liter of water used in the enema
preparation reduces the risk for
hypervolemia
Note!
If a patient is thought to have a perforation in the digestive tract,
barium sulfate is contraindicated because the body does not absorb
barium sulfate naturally.
 Common Procedures for which BaSO4
Suspensions are used:
Area Concentration Method of Px Preparation Px Instruction & Care
(wt/vol %) Administration during Procedure
Esophagus: 30-50 Oral None Supportive communication
Esophagogram Esophageal varices: Px
should exhale, swallow
barium & then hold his/her
breath on that exhalation
Stomach: UGIS 30-50 Oral NPO after midnight before Supportive communication
examination
Small Intestine: 40-60 if Oral Low-residue diet for 2 days Supportive communication
SBS included with before examination
stomach
Large Intestine: 12-25 Rectal Fluid diet day before Supportive communication
Barium enema examination, NPO after
midnight & cleansing
enema before examination
Characteristics of Barium Sulfate
▪ High atomic number (56) producing good radiographic contrast
▪ Insoluble
▪ Stable
▪ Relatively inexpensive
▪ Excellent coating properties of the gastrointestinal mucosa
▪ The concentration of barium in the solution is normally stated as
a percentage weight to volume ratio
Adverse Reaction
▪ Barium sulfate residue within the colon can dry and cause an obstruction.
▪ Major symptom of obstruction: constipation
▪ Perforation of the colon with extravasation into the abd. cavity -
complication related to the administration of barium sulfate during a lower
GI examination
▪ Barium peritonitis

Contraindications for lower GI series:

▪ Older patients with long-term steroid medication
▪ Patients with diverticulitis and ulcerative colitis
▪ Recent biopsy of the colon
▪ Patients with toxic megacolon
▪ Sedative pre-medication
Adverse Reaction
▪ Vaginal rupture, a rare complication of barium sulfate
administration – caused by incorrect placement of the
catheter before lower GI examinations.
▪ Water absorption from the colon – serious complication
of lower GI administration of barium sulfate suspensions

Other Contraindications:
• Sedated patients

• Aspiration

• Allergies
Water Soluble
Iodine CM
Ionic Iodine Contrast Media
• Iodine – 53 Z
• Dissociate into two molecular particles in water or blood
plasma, just as table salt does
• Anion: has a negative charge
• begins with a six-carbon bonded hexagon called
benzene
• Cation: has a positive charge.
• Different classes of ionic media: diatrizoate, metrizoate, and
iothalamate
• Most ionic iodine contrast media are identified as higher
osmolality contrast media because of their osmotic effects.
Ionic Iodine Contrast Media
• Osmolality – measure of the total number of particles in
solution per kilogram of water
• Most adverse reactions to contrast media have been related to
the osmolality of the media
Non-ionic Iodine Contrast Media
▪ Do not dissociate into anions and cations
▪ Ioxaglate (hexabrix) - ionic molecule composed of two connected
benzene hexagons, one that carries an acid group that dissociates
on injection
▪ Dimer
▪ Nonionic dimer, iodixanol (Visipaque)
▪ Made to be isomolal (having the same number of particles) to
blood plasma by the addition of electrolytes, small anions, and
cations, which are normally present in blood plasma
▪ Ioversol (Optiray) – water-soluble nonionic iodine contrast agents
Osmotic Effects
Osmosis – water moves from an area of high concentration to an
area of low concentration
▪ Hypervolemia and blood vessel dilatation, producing pain and
discomfort
▪ Blood pressure may decrease
▪ Dehydrated patients – osmotic effect further reduces body cell
volume and can result in shock.
Allergic-like Effects (Anaphylactoid)
• Mild: Urticaria (hives)
• wheezing and edema in the throat and lungs, with
accompanying bronchospasm
• Nausea and vomiting

• These reactions are thought to be caused by the release of a

substance called histamine from certain cells found in the
lungs, stomach, and lining of blood vessels.
Renal Effects
• High-osmolality contrast media can cause the arteries of the
kidneys to expand as a result of the osmotic effect
• Constriction of the renal arteries
• Osmotic diuresis and dehydration
• Increased blood urea nitrogen (BUN) and creatinine (waste
product of metabolism)

• Theophylline – substance found in tea, currently being

investigated as a preventive of toxic renal effects by increasing
the filtering action of the kidneys
Drug Interactions & Considerations
• Beta-adrenergic blockers – reduce cardiac output
• At increased risk for anaphylactoid reactions during
procedures in which water-soluble iodine contrast media
are used.
• Calcium-channel blockers – reduce hypertension by relaxing
electrical conduction of cell membranes in arterioles (small
arteries) and in heart muscle
• Metformin (Glucophage) – type of drug used to treat non–
insulin-dependent diabetes
• Should be discontinued for 48 hours before and 48 hours
after the use of iodine contrast media
Use of low-osmolality (nonionic) contrast media might
include the following:
• Patients with a history of adverse reactions to contrast media,
excluding mild reactions such as the sensation of heat or
flushing
• Patients with a history of asthma or allergies
• Patients with known cardiac problems
• Patients with generalized severe debilitating conditions
• Patients who will undergo helical CT procedures
 Some Procedures for Which Water-Soluble Iodine Contrast Media Are Used

Area Contrast Agent Methods of Patient Preparation

Administration
Cerebral angiography Usually nonionic Injection into vein or Liquid diet, sedation,
artery intravenous fluids
Thoracic angiography Usually nonionic Injection into vein or Liquid diet, sedation,
artery intravenous fluids
Lower limb: Usually nonionic Injection into vein Sedation &
Venography intravenous fluids
Myelography Only nonionic Injection into Liquid diet, sedation
subarachnoid space
Excretory urography Usually nonionic Injection into vein or Liquid diet, laxatives
artery & cleansing enema,
emptied bladder
Cardiac Usually nonionic Usually through Low-residue diet,
catheterization catheter antibiotic,
intravenous fluids
Ionic and Non-ionic CM
IONIC CONTRAST AGENTS NONIONIC CONTRAST AGENTS
Have greater osmolarity
(Hyperosmolar)
More toxicity(more like to cause
adverse reaction)
Less expensive
Examples:
Gastrografin (Diatrizoate)
Hypaque
Conray
Low osmolarity
Less toxicity (less likely to
cause adverse reaction)
More expensive
Examples:
Ultravist (Iopromide)
Optiray (Ioversol)
Omnipaque
Patient Assessment Prior to Contrast Administration:
1. Patient’s age
2. History of impaired hepatic function (liver disease)
3. History of impaired renal function (kidney disease)
4. History of allergic or anaphylactic reactions
5. History of thyroid disease
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
13. History of seizures
14. Medication history
15. History of previous reactions to medications or contrast agents
16. Allergy to seafood
Side Effects
▪ Expected side effects: feeling of warmth and flushing and
a metallic taste in the mouth
▪ Ionic, high-osmolality iodinated contrast agents are most
frequently associated with adverse events (mild to
severe)
▪ Vasovagal response – fourth reaction
Clinical Manifestations of Expected Side
Effects:
▪ A feeling of flushing or warmth
▪ Nausea and/or vomiting
▪ Headache
▪ Pain at the injection site
▪ Altered taste, may be metallic
Radiographer’s Response:
▪ Slow the rate of the contrast infusion.
▪ Observe the patient closely and offer reassurance.
Clinical Manifestations of a Vasovagal
Reaction
▪ Pallor
▪ Cold sweats
▪ Rapid pulse
▪ Syncope or complaint of feeling faint
▪ Bradycardia
▪ Hypotension
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 Manifestations of Mild Adverse
Reaction
▪ Nausea, vomiting
▪ Cough
▪ Feeling of warmth
▪ Headache
▪ Dizziness
▪ Shaking
▪ Itching
▪ Pallor
Radiographer’s Response:
1. Stop the infusion and notify the radiologist or radiology nurse.
2. Remain with the patient and offer reassurance.
3. Prepare to assist in the administration of an antihistamine or
subcutaneous epinephrine.
Clinical Manifestations of a Moderate
Adverse Reaction
▪ Tachycardia or bradycardia
▪ Hypertension or hypotension
▪ Dyspnea
▪ Bronchospasm or wheezing
▪ Patient complains of feeling of throat closing
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
aspiration.
Clinical Manifestations of a Severe
Anaphylactic Reaction
▪ Dyspnea related to laryngeal edema
▪ Hypotension
▪ Seizures
▪ Cardiac arrhythmia
▪ Lack of patient response
▪ Cardiac arrest
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