LEARNING OUTCOMES:

Upon completion of this lesson, the radiologic technology

student can:

STUDENT’S ACTIVITY SHEET 1. The principles of pharmacology as applied to the practice

of radiography.
2. The properties and use of parenteral contrast media in
LESSON TITLE: Venipuncture Techniques and the practice of radiography.
RTE 010 PHARMACOLOGY AND 3. The methods and techniques for administering drugs and
VENIPUCTURE contrast media.
BS RT/MT / SECOND YEAR 4. The proper techniques for venipuncture.
5. To understand the risk factor and allergic reactions
cause by the administration of Contrast Media

Materials:
Adverse reaction to IV Contrast Media and
Medication LESSON REVIEW/PREVIEW (10 minutes)
Book, pen and notebook, index card/class list

After the instructor give a brief overview on Introduction in Pharmacology and Venipuncture, it`s time to assess the
student`s understanding through answering the following questions:

1. What is Piggyback means?

2. What are the examples of Colloid and Crystalloid Solutions?

3. Importance of bolus in administering contrast media?

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MAIN LESSON (50 minutes)
Students will gain knowledge and learn about this lesson:

Phlebotomy – is taken from the Greek word “Phleb” means referring a vessel” and “tomy” means to make an
incision) The procedure is known as a venipuncture which is the process of performing an incision or making a cut
or wound using a sharp object. Phlebotomist is called to the person has the title, who performs phlebotomy but in
many countries doctors and nurses do of some work of phlebotomy procedures.

Phlebotomists | Phlebotomy Technician a collector of blood samples is their primary function by making an
incision to patients by means of venipuncture or mirotechniques. Venipuncture is a puncture to a vein for
widrawal of blood and administering drug or radiopaque dye used for radiographic purposes.

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.

Contrast materials enter the body in one of three

ways.

They can be:

∙ swallowed (taken by mouth or orally)

∙ administered by enema
(given rectally)
∙ injected into a blood vessel (vein or artery; also called
given intravenously or intra-arterially)

Venipuncture
Sites

Phlebotomists may choose to draw blood from several

different
sites of the
body

Most commonly, venipuncture will be performed on the

Antecubital Fossa, or the inside of the elbow. Here
phlebotomists will typically choose from three veins: the
median
cubital vein, the cephalic vein or the basilic
vein.

If the tech is not comfortable with any of the veins in the

inside
elbow area, they may choose a dorsal vein in the hand or,
as a
last resort, choose a vein in the
foot.

In some cases, a phlebotomist may have to switch sites if they

find the blood is not properly flowing from the vein.
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Venipuncture Procedure

Position the patient so that the vein is easily accessible and you are able to
perform the venipuncture in a comfortable position. Always have the patient
either
lying in bed or sitting in a chair with the arm
propped up.

1. Explain the procedure to the

patient.

2. Apply tourniquet around the arm approximately 2 to 3 inches above the

antecubital fossa (the depression in the anterior region of the elbow) with
enough
tension so that the VEIN is compressed, but not the ARTERY. A BP cuff
(sphygmomanometer) may be used instead of a tourniquet if a patient is difficult
to draw.

3. Position the patient’s arm extended with little or no flexion at the elbow.

4. Locate a prominent vein by palpation (feeling). If the vein is difficult to find, it may be made more prominent by
massaging the arm with an upward motion to force blood into the vein.

5. Cleanse the puncture site with a 70% alcohol pad or povidoneiodine solution and allow to dry.

6. “Fix” or hold the vein taut. This is best accomplished by placing the thumb under the puncture site and exerting a
slight downward pressure on the skin or placing the thumb to the side of the site and pulling the skin taut laterally.

7. Using a smooth continuous motion, introduce the needle, bevel side up, into the
side of the vein at about a 15degree angle with the skin.

8. Hold the one hand and release the tourniquet with the
other.

9. Place a sterile gauze over the puncture site and remove the needle with a quick,
smooth motion.

10. Apply pressure to the puncture site and instruct the patient to keep the arm in a
straight position. Have the patient hold pressure for at least 3
minutes.

11. Re-inspect the puncture site to make sure bleeding has stopped, and apply a
bandage.
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Intravenous Radiocontrast Media: A Review of Allergic Reactions

Intravenous radiocontrast, or IV dye, is used for many different diagnostic procedures to enhance the images in
various radiologic studies. Examples of studies include computed tomography (CT) scans, angiograms, and
Pyelogram. These diagnostic procedures are done on a daily basis in hospital interventional radiology and
cardiology departments around the world. In general, they are used to enhance the visibility of blood vessels.

There are two basic types of contrast media that are used for most radiologic studies: ionic high-osmolality contrast
media and non-ionic low-osmolality contrast media. The latter has become the preferred form of IV dye in recent
years, given its better safety record, especially for women who are breastfeeding. However, it is far more
expensive than high-osmolality contrast media. Allergy reactions to IV dye are common, can range from mild to
moderate, and can sometimes be life
threatening.

It is believed that people who have an allergy to seafood (shellfish) may show an allergy to contrast media as well,
due to the presence of iodine in both. We will briefly review the types, applications, and allergy profile of these
products in this article.

Types of Radiocontrast Media

Both high-osmolar contrast media (ionic) and low-osmolar contrast media (nonionic or organic) agents contain
iodine and are administered intravenously. Most intravascular contrast media are derivatives of tri-iodobenzoic
acid. The iodine molecule is an effective x-ray absorber in the energy range where most clinical systems operate.
Iodinated contrast media are the most efficient products to enhance the visibility of vascular structures and organs
during radiographic procedures. The ionic type creates more charged particles and causes a high osmolality in
blood, which may cause a potentially life threatening contrast media reaction in some individuals with medical
conditions. The nonionic agents generate less dissociation and particles and decrease this risk, but are much more
expensive. The nonionic contrast media are much more widely used today. The iodine concentration of contrast
media is determined by the number of iodine molecules in milligrams present in a milliliter of a solution (mg/mL).

Concentration of any contrast media agent determines how radiopaque the agent will be. The higher the iodine
concentration, the better the chance that more x-ray photons will be absorbed. Therefore, that particular contrast
agent may be more radiopaque than a comparable low-iodine concentrated agent.

The osmolality of a solution is the measurement of the number of molecules and particles in a solution per kilogram
of water. In other words, osmolality can be described as a measurement of the number of molecules that can crowd
out or displace water molecules in a kilogram of water. The radiographic significance of the osmolality value of
contrast media is that it is
higher than the osmolality value of blood plasma. Any solution that has an osmolality value greater than blood
plasma is said to be a hyperosmolar solution. Therefore, ionic and nonionic contrast media are hyperosmolar
solutions when compared to blood plasma.

Since certain radiographic procedures, such as myelography, cannot use ionic contrast media, the discovery of
nonionic contrast media in 1974 (e.g., metrizamide) revolutionized these procedures.

Contrast Media Applications

Examples of currently used ionic and nonionic contrast media are perflutren-protein type-A microspheres injection
(Optison), iohexol injection (Omnipaque), and nonionic iodixanol injection (Visipaque).

Optison is used in patients with suboptimal echocardiograms to opacify the left ventricle and to improve the
delineation of the left ventricular endocardial borders.

Omnipaque is used for angiocardiography; aortography including studies of the aortic root, aortic arch, ascending
aorta, and abdominal aorta and its branches; contrast enhancement for CT scan of head and body imaging; IV
digital subtraction angiography (DSA) of the head, neck, abdominal, renal, and peripheral vessels; peripheral
arteriography; and excretory urography.

Nonionic or organically bound iodine contrast media such as Visipaque (270 mgI/mL) are used for DSA. Visipaque
Injection (320 mgI/mL) is used for angiocardiography, peripheral arteriography, visceral arteriography, and cerebral
arteriography.
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Visipaque Injection (270 mgI/mL and 320 mgI/mL) is indicated for CT of the head and body (excretory urography).
Visipaque Injection (270 mgI/mL) is also indicated for peripheral venography. Another example of the nonionics is
Isovue-300 (iopamidol), which is used to help diagnose certain disorders of the heart, brain, blood vessels, and
nervous system.

Dosing and Administration

It is reported that the calculation of contrast media dose and injection rate on the basis of lean body weight leads to
increased patient-to-patient uniformity of hepatic parenchymal and vascular enhancement. This is likely related to
the greater perfusion of contrast media to solid organs, muscles, and vessels compared with the highly variable but
poorly perfused adipose tissue. As an example, the volume and injection rate of contrast material administration
based proportionately on a 70-kg man with 25% body fat or a 70-kg woman with 30% body fat is about 45 g iodine
IV at 0.9 g/sec.

The rate or speed of contrast media injections may increase the risk of an adverse reaction. Also, the viscosity or
thickness of the contrast media can cause resistance to its flow. The viscosity is related to the concentration, the
size of the molecules in a specific contrast agent, and the temperature of the contrast agent. Contrast media with
higher viscosity values should be injected at a slower rate. Heating the contrast media, usually to body
temperature, reduces viscosity. Iodine concentration, viscosity, temperature of the contrast media, catheter inner
diameter, catheter length, and the number of catheter holes are all factors that influence contrast media flow.

Allergies
In most cases, shortly after infusion, iodinated contrast media cause a warming sensation throughout the body. In
certain areas of the body this feeling is more pronounced. Patients receiving contrast media via IV typically
experience a hot feeling around the throat, and this hot sensation gradually moves down to the pelvic area.

Reactions to IV dye are observed in 5% to 8% of patients who receive them. Mild reactions include a feeling of
warmth, nausea, and vomiting. Generally, these symptoms occur only for a short period of time and do not require
treatment. Moderate reactions, including severe vomiting, hives, and swelling, occur in 1% of patients receiving
contrast media and frequently require treatment. Severe, life-threatening reactions, including anaphylaxis, occur in
0.1% of people receiving contrast media, with an expected death rate of one person in every 75,000. The most
severe reactions, including death, have been reported to occur at similar rates with both types of contrast media.

Reactions to contrast media are not a true allergy, but rather a pseudoallergy in nature, meaning that there is no
allergic antibody present that causes the reaction. Rather, contrast media act to directly release histamine and
other chemicals from mast cells. The iodine concentration has an effect on the severity of an adverse reaction. The
higher the iodine concentration, the greater the risk of an adverse reaction.

Iodinated contrast media are toxic to the kidneys and kidney functions. The serum creatinine of the patient
receiving a dose should be monitored before the procedure. In addition, the estimated glomerular filtration rate
(eGFR) should be no lower than 30 mL/min in patients receiving iodinated contrast, and discretion should be used
in patients with eGFR less than 45 mL/min. Following injections with extra fluids is highly recommended.

Numerous studies have shown that although iodine is common in contrast media, iodine is not the cause of allergic
reactions. Certain proteins in seafood, rather, are the cause of allergy in patients with seafood allergies. It is noted
that true allergic effects are by definition immunoglobulin E–related, and studies have shown that contrast media
cause no such reaction in vivo. Therefore, contrast media or the iodine is not likely to act as an allergen.

Radiocontrast Media Allergy Diagnosis

Skin testing and RAST (radioallergosorbent test) have not been helpful in the diagnosis of contrast media allergy.
Small “test” doses are also not helpful, with reports of severe, life-threatening reactions occurring even at such
amounts. Severe reactions to larger doses of contrast media have been observed after a person tolerated a small
dose of IV dye. Therefore, the diagnosis of contrast media allergy is made only after symptoms have occurred.
Otherwise, it is only possible to determine that a person is at increased risk of a reaction to contrast media based
on the risk factors outlined below.

Allergy Prevention and Treatment

As mentioned above, the purpose of using these contrast agents is for diagnosis, but like any medical procedure in
any radiological study, the right dose or volume of contrast media needs to be determined prior to a procedure.
The total volume or dose is dependent upon several factors: iodine concentration of the contrast media; type of
injectable contrast media (ionic or nonionic); patient’s body weight, anatomical structures or regions; speed of the
injection; and age or disease
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process that could increase the risk of an adverse reaction. The treatment of an acute reaction to contrast media is
no different from any other anaphylactic reaction. Treatment may include injectable epinephrine and
antihistamines, as well as the use of IV fluids for low blood pressure and shock.

Contrast media reactions can be prevented by a test dose for the intended contrast or the use of an alternative; the
use of nonionic versus ionic media if applicable; and the use of certain medicines prior to the administration of
contrast media such as prednisone 50 mg orally taken at 13, 7, and 1 hour prior to procedure, or diphenhydramine
(Benadryl) 50 mg orally, IV or intramuscularly, 1 hour prior to receiving radiocontrast media.

Risk Factors
As mentioned above, people who have seafood allergy are not at risk if they need to use contrast media. In
addition, people with an allergy to topical iodine cleaners or iodides are also not at increased risk for reactions to
contrast media. Patients who are at higher risk include those with past reactions to contrast media (up to 44%);
those with asthma; those who have a history of heart and kidney and thyroid (both hypo- and hyperthyroidism)
diseases; those taking beta-blockers or metformin; and females and the elderly (appear to be at higher risk for
severe reactions).

Note: Timely follow-up of serum creatinine levels in patients with diabetes who are receiving metformin therapy is
highly important, and monitoring is required by pharmacists. Nearly 4% of patients with diabetes mellitus and
normal renal function may develop contrast material–associated neuropathy with nonionic contrast media. Roughly
8% of patients with diabetes receiving metformin, whose baseline serum creatinine levels are below 1.5 mg/dL,
develop an increased risk of lactic acidosis requiring metformin therapy to be withheld for at least 48 hours after
administration of IV contrast material. The FDA currently recommends metformin monitoring in patients who are
undergoing radiologic procedures involving administration of IV contrast media.

Discontinuing an IV infusion:

∙ Check the physician's order to see if the IV site is to be

discontinued or if the site needs to be changed to an
intermittent device.
∙ Clamp the IV tubing
∙ Undo the tape (if a bio-occlusive dressing is used,
stretching the dressing will help release it from the
patient's
skin) by peeling the tape toward the IV site
∙ Loosely hold a sterile cotton ball or dressing on the IV site
∙ Withdraw the IV cannula, immediately put pressure on the
site, and if possible raise the arm so that IV site is above
the level of the heart
Hold pressure until the bleeding has stopped (this may
be
several minutes if the patient is receiving anticoagulant
therapy)

CHECK FOR UNDERSTANDING (30 minutes)

-The instructor will prepare 10-15 questions that can enhance critical thinking skills. Students will work by
themselves to answer these questions and write the rationale for each question.

(Teacher creates a short quiz for students to check how well they understood the lesson)
(Check for Understanding may also be a summative test which the teacher will check and grade)

Multiple Choice
(For 1-10 items, please refer to the questions in the Rationalization Activity)

1. Called to the person has the title, who performs phlebotomy

A. Histologist
B. Radiologist
C. Phlebotomist
D. Radtech
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Answer: ____
___________________________________________________________________________________________
______ _________________________________________________________________________________

2. It is used in patients with suboptimal echocardiograms to opacify the left ventricle and to improve the
delineation of the left ventricular endocardial borders
A. Omnipaque
B. Optison
C. Visipaque
D. Non-ionic

Answer: ____
___________________________________________________________________________________________
______ _________________________________________________________________________________

3. These 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.
A. Dye
B. Radiocontrast agents
C. Intravenous Radiographic contrast
D. AOTA

Answer: ____
___________________________________________________________________________________________
______ _________________________________________________________________________________

4. Any solution that has an osmolality value greater than blood plasma is said to
be____________ A. hyperosmolar solution
B. hypoosmolar solution
C. radiographic solution
D. NOTA

Answer: ____
___________________________________________________________________________________________
______ _________________________________________________________________________________

5. It described as a measurement of the number of molecules that can crowd out or displace water molecules in
a kilogram of water.

A. ionic concentration
B. non-ionic compounds
C. osmolality of a solutions
D. hyperosmolar solution

Answer: ___
___________________________________________________________________________________________
______ _________________________________________________________________________________

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