Case report
Management of large volume CT contrast medium extravasation injury: technical refinement and literature review

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Summary

The incidence of radiographic contrast medium extravasation is on the rise due to the rapid increase in availability of contrast enhanced imaging. There is no consensus, however, regarding its management. There is a wide spectrum of clinical presentations, ranging from localised erythema and oedema to skin necrosis, which is related to the osmolarity and volume of the extravasated contrast medium. It is not possible to predict the degree of final tissue injury at initial examination. The increase in use of automated bolus injection has led to an increase in incidence of large volume extravasation injuries. Here we present a review of the literature regarding clinical presentation, risk factors, and management of contrast extravasation injuries. We also report the management of a large volume computed tomography contrast extravasation injury following mechanical bolus injection using a combination of liposuction and saline washout as described by Gault, and the use of compression by a Rhys-Davies exsanguinator as a technical refinement to achieve immediate resolution of the soft tissue oedema.

Section snippets

Background

Extravasation of contrast medium is a well-described complication of contrast-enhanced imaging. Its incidence is on the increase and yet there is no consensus regarding treatment. The European Society of Urogenital Radiology (ESUR) has recently produced guidelines for the prevention and management of contrast medium extravasation injuries at the International Symposium on Urogenital Radiology.1 There is a wide spectrum of clinical presentations, with the majority of patients presenting with

Risk factors

Infants, young children, and unconscious patients are particularly at risk because they are unable to report pain when extravasation occurs. Extravasation injury is more severe in patients with thin atrophic subcutaneous tissue, and is poorly tolerated in those with impaired peripheral vascular or lymphatic circulation. Injection sites in the lower limb and small distal veins have a higher risk of extravasation.

Osmolarity

Low-osmolar contrast media extravasations are better tolerated than those involving high-osmolar iodinated media.2 There is conflict in the literature regarding whether ionic contrast media are more cytotoxic than non-ionic media. It has been shown in the animal model that although non-ionic agents produce inflammatory reactions and focal necrosis in soft tissues, they are much better tolerated than ionic agents.3

Volume of extravasation

Most extravasation injuries involve low volumes of contrast and symptoms resolve within 24 h. Large volume extravasations are most likely to result from mechanical bolus injection, where the injection site cannot be closely monitored due to ionising radiation safety precautions. The extravasation rate following automated power injection ranges from 0.1 to 0.9% of patients in the literature.4, 5, 6 Severe tissue injury is most likely to result from large volume extravasations. The mechanical

Signs and symptoms

There is wide variability in the clinical presentation. Patients may complain of pain at the injection site, with local oedema, erythema, and tenderness to palpation, which all resolve within 24 h. It is important to note that it not possible to predict the degree of final tissue injury at initial examination.8 The presence, however, of skin blistering, altered tissue perfusion, paraesthesia, and increasing or persistent pain after 4 h suggest severe injury.1 Large volume extravasations in the

Management

Although there is no consensus regarding management, the following guidelines have been published by the members of the Contrast Media Safety Committee of the ESUR:

  • 1.

    Elevate the affected limb. Elevation reduces oedema by decreasing the hydrostatic pressure in capillaries.

  • 2.

    Application of ice packs. Cooling produces vasoconstriction and limits inflammation.

  • 3.

    Careful monitoring with consideration of surgical treatment if serious injury is suspected.

Hyaluronidase

Hyaluronidase facilitates absorption of extravasated media by catalysing the breakdown of hyaluronic acid, the dominant glycosaminoglycan in connective tissue. Conflicting results have been published regarding its efficacy, although most clinical studies report a beneficial effect.4

Surgical management

Surgical drainage or liposuction within 6 h can be effective, and saline washout as originally described by Gault8 has been shown to be helpful. To date there have been no randomised trials comparing conservative management with surgical treatment. In the series of 96 patients studied by Gault the treatment of extravasation injuries comparing liposuction, saline flushout, and combinations, was addressed. A limit of 24 h after the injury was used as the cut-off time in the series. Only one of the

Case report

A 72-year-old woman underwent elective contrast-enhanced CT scanning of the abdomen. An automated power injector was used to inject a volume of 100 ml contrast medium into an intravenous cannula in a superficial vein at the dorsum of the left hand. The contrast medium used was iopamidol (300 mg I/kg; Niopam 300, Bracco s.p.a., Milan, Italy), which is non-ionic and of low osmolarity. Following completion of injection the dorsum of the hand was noticed to be swollen, painful, and erythematous. The

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