Contrast media extravasation

Radswiki et al.

Contrast media extravasation (CMEV) is a well-known complication of contrast-

enhanced CT scanning . It can also occur in MRI studies, but the complications
1

are rare given the low volume that are used.

Epidemiology
CT contrast extravasation occurs relatively infrequently, in ~0.5% (range 0.13-
0.68%) of cases, but can have severe side effects associated with skin changes
and possible skin necrosis.

Risk factors
 increased incidence with automated power injection because large volumes
can extravasate in a short period of time 2

o with manual injection, extravasation is thought less likely, as there is direct

supervision of contrast administration
 patient-related factors
o elderly patients
o emaciated patients
o oedematous patients
o confused patients
 site of venous access:
o higher percentage of leakage in the venous access in the back of the hand,
wrist, foot and ankle
o likely related to a smaller amount of subcutaneous tissue and the fact that
veins are more fragile on these regions
 the gauge of intravenous catheter: only if smaller calibre access (over 22G) is
used; risk of leakage is the same for 18G and 20G 1

 high-osmolar contrast medium 2

o pre-warming of high-osmolar (370 mg/ml) lowers the viscosity and has been
proven to lower the probability of extravasation5

 additionally a recently published study "incidence of contrast medium

extravasation for CT and MRI in a large academic medical centre: a report on
502,391 injections" showed that 3

o patients undergoing CT are at higher risk of developing CMEV than MRI

patients
 o females and inpatients were also more likely to develop CMEV at both CT
and MRI
o at MRI, CMEV is more likely in patients above the age of 60 years and for
those receiving automated power injections

Pathology
Nonionic low-osmolar contrast media is known to reduce the risk of severe soft
tissue injury, but the potential for soft tissue injury is often related to the volume of
CME . 1

Treatment and prognosis

The conduct after an episode of CMEV will vary according to the protocol of each
radiology department, and might include:

 discontinue the contrast infusion and notify the radiologist immediately

 complete the acquisition of images of the CT series
 attempted aspiration of the extravasation has not been shown to be effective
 apply an ice pack to the affected area and elevate the affected extremity to
reduce swelling
 keep the patient under observation for at least 2 hours
 at some institutions, the policy is to require plastic surgery consultation for all
patients whose extravasations involve 100 ml or more of contrast medium
 make contact with the doctor requesting the examination
 it is suggested to follow up the patient in the next few days until the resolution
of local oedema; this can be accomplished with a phone call to evaluate the
regression of the signs and symptoms
 instruct the patient to notify staff if there is
o increasing swelling or pain over time
o blistering, ulceration, induration or other skin changes
o altered tissue perfusion and/or changes in sensation

Complications
Most CMEV results in minimal swelling or erythema and have no long-term
sequelae . A large study found that >97% of patients with contrast extravasation
2

had minimal or no injury and reported that 79% of patients had localised swelling
after extravasation, 24% had pain, and 8% were asymptomatic . 4
Large volumes (>50 ml) of high-osmolar contrast media are known to induce
significant tissue damage

 skin ulceration
 soft-tissue necrosis
 compartment syndrome