Patient preparation for a PET (Positron Emission Tomography) scan is a critical process that involves

several key steps to ensure the success of the imaging procedure and the safety and comfort of the
patient. PET scans are valuable in diagnosing various medical conditions, including cancer,
cardiovascular disease, and neurological disorders. Proper preparation is essential to obtain accurate
and reliable results. Here is a comprehensive guide on patient preparation for a PET scan.

**1. Communication and Education:**

Effective communication between healthcare providers and patients is fundamental in preparing for
a PET scan. Patients need to have a clear understanding of the purpose of the scan, the procedure
itself, and any necessary preparations. This information helps alleviate anxiety, build trust, and
ensures the patient's active participation in their healthcare.

Healthcare providers should explain that a PET scan involves the use of a small amount of radioactive
material (tracer) and a special camera to capture images of the body's metabolic activity. Patients
should be informed that the radiation exposure from a PET scan is generally minimal and outweighed
by the diagnostic benefits.

**2. Informed Consent:**

As with any medical procedure involving radiation or contrast agents, obtaining informed consent is
crucial. Patients should receive detailed information about the risks and benefits of the PET scan,
potential allergic reactions (if any contrast material is used), and the overall process. Written consent
should be obtained, demonstrating that the patient has been adequately informed and willingly
agrees to undergo the examination.

**3. Fasting and Dietary Restrictions:**

Patient preparation for a PET scan often involves specific dietary instructions. In many cases, patients
are required to fast for a certain period before the scan, typically around 4-6 hours. Fasting helps
ensure that the body's glucose levels are stable, which is crucial for the uptake of the radioactive
glucose tracer during the scan. Patients should follow these fasting instructions meticulously to
optimize the quality of the PET images.

Additionally, patients should avoid consuming high-carbohydrate meals or sugary foods on the day of
the scan, as this can impact the distribution of the radioactive tracer. Clear communication of dietary
restrictions is essential to prevent any deviations that might affect the accuracy of the scan.
**4. Blood Glucose Monitoring:**

Monitoring blood glucose levels is a critical aspect of PET scan preparation, especially for exams that
use a glucose-based tracer. Elevated blood glucose levels can compete with the radioactive glucose
tracer, potentially leading to suboptimal imaging results. Therefore, patients with diabetes or those
at risk of elevated blood glucose should monitor and manage their levels closely in the hours leading
up to the scan.

If a patient's blood glucose levels are too high, the PET scan may need to be rescheduled after
appropriate glucose control is achieved. This emphasizes the importance of patient compliance with
fasting instructions and any prescribed medications.

**5. Medication Review:**

Patients should provide a comprehensive list of their current medications to the healthcare team.
Certain medications, particularly those affecting glucose metabolism, may need to be temporarily
discontinued or adjusted before the PET scan. It's crucial for healthcare providers to review the
medication list and provide specific instructions to the patient based on their individual needs.

**6. Hydration:**

While fasting is generally required for a PET scan, patients are typically encouraged to stay well-
hydrated. Adequate hydration helps ensure the proper distribution and elimination of the radioactive
tracer from the body. Patients should drink water in the hours leading up to the scan, unless
instructed otherwise by their healthcare provider.

**7. Contrast Material and Allergies:**

In some cases, a PET scan may be combined with a CT scan to provide more detailed anatomical
information. If contrast material is used for the CT portion of the scan, patients need to inform their
healthcare team about any allergies, particularly to iodine-based contrast agents. Precautions can be
taken to minimize the risk of allergic reactions, and alternative imaging modalities may be considered
if necessary.

**8. Pregnancy and Breastfeeding Considerations:**

It is crucial for female patients to inform their healthcare provider if there is a possibility of
pregnancy or if they are breastfeeding. Radiation exposure during pregnancy can have potential risks
to the developing fetus, and alternative imaging options or postponing the scan may be considered
in such cases.

If a patient is breastfeeding, they may need to pump and store breast milk before the PET scan, as
the radioactive tracer can be present in breast milk for a period after the procedure. Temporary
cessation of breastfeeding might be recommended based on the type of tracer used and the half-life
of the radioactive material.

**9. Comfort and Anxiety Management:**

The unfamiliarity of medical procedures can contribute to patient anxiety. Healthcare providers
should take steps to create a comfortable and supportive environment for the patient. Explaining the
procedure in detail, addressing concerns, and offering reassurance can go a long way in ensuring the
patient feels at ease during the PET scan.

**10. Post-Procedure Care:**

After the PET scan, patients can typically resume their normal activities. However, it's essential to
remind patients to stay well-hydrated to aid in the elimination of the radioactive tracer. Patients
should be informed about any specific post-procedure instructions, potential side effects, and when
they can expect to receive the results of the scan.

\
 Prepare a Patient for a Procedure in Interventional Radiology
Each patient will receive a call from a nurse at least five days prior to the
appointment unless the appointment is made less than five days prior to the
scheduled date and time. During this call, the nurse reviews the patient’s
medical history and medication list and gives the patient instructions based on
the type of procedure that is scheduled.

General Instructions
Patients who are undergoing outpatient procedures should arrive 1 hour before
their scheduled appointment time and check-in at the radiology front desk
(room 1145) in the main Vanderbilt University Hospital.

Patients who are undergoing a procedure that requires overnight observation

should arrive 1.5 hours before their scheduled appointment time and should
stop by the admitting office prior to checking in at the radiology front desk.

Patients should leave all valuables at home.

Patients who will receive sedation or anesthesia during their procedure must
have a friend or family member available to drive them home and care for
them for the next 24 hours.

Most procedures that involve sedation last 1 to 2 hours with a 2 to 4 hour

recovery period following the procedure. The patient should expect to be here
for at least 4 to 6 hours.

NPO (Fasting) and Medication Instructions

Only patients who will receive sedation or anesthesia during the procedure need
to be NPO.

 No solid food or milk products for 6 hours prior to the procedure.

 No clear liquids for 2 hours prior to the procedure.
 Take all regular medications as scheduled with small sips of water
unless otherwise directed.
 For medicine for diabetes: take only half dose of evening insulin; hold
morning insulin and oral diabetic medication the day of the procedure.
 There are many anticoagulants, aspirins and non-steroidal anti-
inflammatory medications that may need to be held prior to your
procedure. Patients should be asked to keep medical team informed of
all medications the patient is taking. If needed, prior to a
 procedure, our team can review specific medications and plan to
manage manage anticoagulation.

Instructions for Holding Medications Prior to Procedures

Medication Instruction
ASA 325mg Hold 5 days
ASA 81mg Do not hold
Plavix Hold 5 days
Coumadin Hold for INR </= 1.5
Lovenox therapeutic dose
Hold 24 hours
(1mg/kg)
Lovenox prophylactic dose
Hold 12 hours
(30 – 40 mg)
Fundaperinux (Arixtra) Hold 24 hours
SQ Heparin Hold AM dose
Aggrenox Hold 7 days
Hold for: 2 days if CrCl>50, 3 – 5 days
Dabigatron (Pradaxa) if CrCl<50

Fragmin Hold dose the day of procedure

Hold 48 hours before liver, lung or kidney
NSAIDs
biopsies
Hold all po and long-acting insulin Take ½
Insulin – if pt NPO short-acting insulin dose the morning of the
procedure
Hold for 48 hours after procedure and confirm
Metformin
normal renal function prior to restarting
 CONTRAST AGENTS

Chapter 7: Contrast Agents in Medical Imaging

Introduction

Medical imaging plays a crucial role in diagnosing and monitoring various medical conditions.
Contrast agents are substances used to enhance the visibility of structures or fluids within the body
during imaging procedures. These agents help improve the diagnostic accuracy of medical imaging
techniques, providing clinicians with better insights into the anatomy and function of organs and
tissues. In this chapter, we will explore the different types of contrast agents used in medical imaging,
their mechanisms of action, applications, and potential risks and benefits.

Types of Contrast Agents

1. **Iodine-based Contrast Agents**

Iodine-based contrast agents are widely used in X-ray and computed tomography (CT) imaging. These
agents contain iodine atoms, which strongly absorb X-rays, leading to increased contrast in the
resulting images. Common iodine-based contrast agents include iohexol, iopamidol, and iodixanol.
These agents are particularly useful for visualizing blood vessels, organs, and tumors in CT
angiography and other vascular imaging studies.

2. **Gadolinium-based Contrast Agents**

Gadolinium-based contrast agents are commonly employed in magnetic resonance imaging (MRI).
Gadolinium, a rare earth metal, has strong magnetic properties that affect the relaxation times of
nearby water molecules, resulting in enhanced contrast in MRI images. Gadolinium-based agents
include gadopentetate dimeglumine, gadobutrol, and gadoterate meglumine. MRI contrast agents
are valuable for imaging soft tissues, such as the brain, liver, and joints, offering detailed anatomical
information.

3. **Ultrasound Contrast Agents**

Microbubble-based contrast agents are used in ultrasound imaging. These microbubbles consist of
gas encapsulated by a shell, typically made of lipids or proteins. When exposed to ultrasound waves,
these microbubbles resonate, creating enhanced echoes that improve the visibility of blood vessels
and cardiac structures. Ultrasound contrast agents are commonly utilized in echocardiography and
vascular imaging.

4. **Barium-based Contrast Agents**

Barium sulfate is a radiopaque contrast agent used in fluoroscopy and X-ray examinations of the
gastrointestinal (GI) tract. Barium suspensions or tablets are ingested or introduced into the GI tract,
allowing for visualization of the esophagus, stomach, and intestines. Barium studies are valuable for
detecting abnormalities such as tumors, strictures, and inflammation in the digestive system.

Mechanisms of Action

The mechanisms of action of contrast agents vary depending on the imaging modality used:

1. **X-ray and CT Imaging**

In X-ray and CT imaging, contrast agents containing high-atomic-number elements, such as iodine,
absorb X-rays more effectively than surrounding tissues. This differential absorption leads to
increased contrast in the X-ray or CT images, highlighting blood vessels, organs, or pathological
structures.

2. **MRI Imaging**

Gadolinium-based contrast agents alter the relaxation times of water molecules in tissues. By
shortening the T1 and T2 relaxation times, these agents enhance the contrast between different
tissues in MRI images. The specific mechanism involves the interaction between the gadolinium ions
and water protons in the tissues.

3. **Ultrasound Imaging**

Microbubble-based ultrasound contrast agents enhance the reflection of ultrasound waves. As the
microbubbles oscillate in response to the ultrasound waves, they produce strong echoes, improving
the visibility of blood flow and vascular structures. This mechanism enhances the sensitivity of
ultrasound imaging in detecting blood flow abnormalities.

Applications of Contrast Agents

1. **Cardiovascular Imaging**

Contrast agents play a crucial role in cardiovascular imaging, particularly in angiography and the
assessment of cardiac function. In CT angiography, iodine-based contrast agents help visualize blood
vessels, aiding in the diagnosis of arterial stenosis, aneurysms, and other vascular abnormalities. In
echocardiography, microbubble-based contrast agents enhance the delineation of cardiac chambers
and improve the detection of myocardial perfusion defects.

2. **Neuroimaging**

MRI contrast agents, such as gadolinium-based agents, are extensively used in neuroimaging. They
assist in visualizing abnormalities in the brain and spinal cord, including tumors, vascular
malformations, and inflammatory conditions. The ability to enhance certain structures or pathologies
helps neurologists and neurosurgeons in accurate diagnosis and treatment planning.

3. **Gastrointestinal Imaging**

Barium-based contrast agents are commonly employed in gastrointestinal imaging studies, including
barium swallow, barium meal, and barium enema. These studies help assess the structure and
function of the esophagus, stomach, and intestines. Barium studies are valuable for diagnosing
conditions such as gastroesophageal reflux disease (GERD), peptic ulcers, and colorectal polyps.

4. **Oncological Imaging**

Contrast-enhanced imaging is crucial in oncology for the detection and characterization of tumors. In
CT and MRI, contrast agents improve the visualization of tumors by highlighting their vascular supply
and enhancing the distinction between normal and abnormal tissues. This aids in tumor staging,
treatment planning, and monitoring treatment response.

5. **Musculoskeletal Imaging**

In musculoskeletal imaging, contrast agents are utilized to evaluate joints, soft tissues, and blood
vessels. MRI with gadolinium-based contrast agents is commonly employed to assess joint disorders,
such as arthritis, and to detect soft tissue abnormalities like tumors or ligament injuries. Contrast-
enhanced imaging provides additional information to guide orthopedic interventions and surgical
planning.
6. **Renal Imaging**

Contrast-enhanced imaging is valuable in assessing renal function and detecting abnormalities in the
kidneys and urinary tract. In renal angiography, iodine-based contrast agents help visualize the renal
vasculature. Additionally, gadolinium-based agents are used in dynamic contrast-enhanced MRI to
assess renal perfusion and function.

Benefits of Contrast Agents in Medical Imaging

1. **Improved Diagnostic Accuracy**

Contrast agents enhance the visibility of anatomical structures and pathological conditions, leading
to improved diagnostic accuracy. The increased contrast allows radiologists and clinicians to identify
subtle abnormalities, differentiate between normal and abnormal tissues, and make more informed
diagnoses.

2. **Enhanced Vascular Imaging**

Contrast agents are particularly valuable in vascular imaging, providing detailed visualization of blood
vessels and aiding in the diagnosis of conditions such as arterial stenosis, aneurysms, and
thrombosis. This is crucial for planning interventions, such as angioplasty or stent placement, in
patients with cardiovascular diseases.

3. **Increased Sensitivity in Tumor Detection**

Contrast-enhanced imaging significantly improves the detection of tumors by highlighting their

vascularity and enhancing the contrast between the tumor and surrounding tissues. This is especially
important in oncology for accurate tumor staging, treatment planning, and monitoring treatment
response.

4. **Visualization of Soft Tissues**

MRI contrast agents are essential for imaging soft tissues, providing detailed information about the
brain, spinal cord, joints, and organs. This is especially beneficial in neurology, rheumatology, and
orthopedics, where the assessment of soft tissue structures is crucial for diagnosis and treatment
planning.

5. **Dynamic Functional Imaging**

Contrast-enhanced imaging allows for dynamic assessment of organ function. In renal imaging, for
example, dynamic contrast-enhanced MRI can provide information about renal perfusion and
filtration. This functional information is valuable in understanding the physiological status of organs
and guiding treatment decisions.

Risks and Considerations

While contrast agents have revolutionized medical imaging, their use is not without risks. It is
essential for healthcare

providers to carefully weigh the potential benefits against the risks and consider alternative imaging
approaches when appropriate. The following are important considerations related to contrast agent
use:

1. **Allergic Reactions**

Some patients may be allergic to certain contrast agents, particularly iodine-based agents. Allergic
reactions can range from mild skin rashes to severe anaphylaxis. Healthcare providers should inquire
about the patient's history of allergies and assess the risk of an allergic reaction before administering
contrast.

2. **Renal Toxicity**

Iodine-based contrast agents have been associated with the risk of contrast-induced nephropathy
(CIN), especially in patients with pre-existing renal impairment. Healthcare providers should assess
renal function before administering contrast and consider alternative imaging methods or adjust the
contrast dose in high-risk patients.

3. **Gadolinium Retention**
Gadolinium-based contrast agents have been associated with gadolinium retention in certain tissues,
particularly in patients with impaired renal function. While the clinical significance of gadolinium
retention is not fully understood, healthcare providers should consider the potential long-term
effects and choose alternative imaging methods or use gadolinium-based agents judiciously.

4. **Pregnancy Considerations**

The use of contrast agents during pregnancy requires careful consideration of potential risks to the
developing fetus. Healthcare providers should weigh the benefits of the imaging study against
potential risks and consider alternative methods or postpone the procedure when feasible.

5. **Cumulative Dose Considerations**

Patients undergoing multiple imaging studies with contrast agents may receive cumulative doses
over time. Healthcare providers should be mindful of the cumulative dose and consider alternative
imaging approaches or use the lowest effective dose necessary for diagnostic purposes.

6. **Alternative Imaging Approaches**

In some cases, alternative imaging methods that do not require contrast agents may be suitable. For
example, non-contrast MRI sequences or non-contrast CT scans may be appropriate for certain
clinical scenarios, reducing the potential risks associated with contrast agents.

Future Developments

The field of medical imaging is continuously evolving, with ongoing research aimed at improving the
safety, efficacy, and versatility of contrast agents. Some areas of active development and research
include:

1. **Nanoparticle-based Contrast Agents**

Nanoparticles are being explored as potential contrast agents for various imaging modalities. These
tiny particles can be engineered to target specific tissues or cells, offering the potential for highly
targeted and personalized imaging approaches.

2. **Multimodal Contrast Agents**

Research is underway to develop contrast agents that can be used for multiple imaging modalities.
These multimodal agents could provide complementary information from different imaging
techniques, enhancing diagnostic capabilities.

3. **Smart Contrast Agents**

Smart contrast agents are designed to respond to specific physiological or pathological conditions.
These agents could be engineered to activate or change their properties in the presence of specific
biomarkers, allowing for more precise and targeted imaging.

4. **Biodegradable Contrast Agents**

Biodegradable contrast agents are being explored to address concerns about the long-term retention
of certain contrast agents in the body. These agents could be designed to break down or be
eliminated from the body after imaging, potentially reducing the risk of adverse effects.

Contrast agents have significantly contributed to the advancement of medical imaging, enabling
clinicians to visualize and diagnose a wide range of medical conditions with greater precision. From
iodine-based agents in X-ray and CT imaging to gadolinium-based agents in MRI and microbubble-
based agents in ultrasound, each type of contrast agent has unique properties that make it suitable
for specific imaging modalities and applications.

As medical imaging technology continues to evolve, ongoing research aims to improve the safety,
efficacy, and versatility of contrast agents. The development of novel nanoparticle-based agents,
multimodal agents, smart contrast agents, and biodegradable agents holds promise for further
enhancing the capabilities of medical imaging.

Healthcare providers must carefully consider the risks and benefits of using contrast agents in each
patient, taking into account factors such as allergies, renal function, and pregnancy status.
Additionally, ongoing efforts to refine imaging protocols, minimize doses, and explore alternative
imaging approaches contribute to the goal of providing accurate and safe diagnostic information for
patient care.