UCSD Musculoskeletal Radiology bonepit.com Contrast extravasation policy

Contrast Extravasation Guidelines

Policy Statement

All proper steps will be taken to avoid contrast extravasation

Responsible Party

Physician Staff, Nursing Staff, Imaging Technical Personnel Staff

General Information:

Extravasation of intravenous contrast agents in the soft tissues may rarely result in severe local damage including chemical inflammation, tissue necrosis and sloughing of the overlying skin. The severity of these agents is related to the volume and hyperosmolarity of the contrast extravasated. Both ionic and nonionic contrast agents are hyperosmolar with the exception of Visipaque, which is isoosmolar and may produce local adverse effects if extravasated. Ionic contrast compounds elicit more severe lesions because they have higher osmolality than non-ionic contrast agents. Contrast extravasation injury may be aggravated by infection which may contribute to substantial tissue loss.

PROCEDURE:

l. Prevention:

The best contrast policy directive regarding extravasation is prevention[DK1] .  When the power injector is utilized, a 20 gauge needle/cannula 1.25 to 1.5 inches in length is preferred for IV contrast injection. It is advisable to obtain a good backflow of blood to test adequate positioning of the needle or catheter in the vein, and then advance the cannula into the vessel. Adequate position of the cannula in the vein is checked again with saline injection before the injector is armed to deliver contrast.

ll. Diagnosis and Evaluation of the Volume

When extravasation of contrast is identified by swelling around the site of the injection and/or the patient experiencing pain, immediately stop the injection.  The volume of contrast extravasated is calculated by subtracting the remaining contrast volume in the syringe or the injector from the initial volume of contrast.

lll. Conditions which increase the risk to develop infection if extravasation occurs include but are not limited to:

·         Diabetes

·         Immunosuppression

·         Cancer

·         Limb ischemia

·         Steroid treatment

·         Scleroderma or other connective tissue disease

lV. Communication

A. Authorized prescriber

1. The responsible authorized prescriber at the time of the occurrence should be informed

    immediately. The authorized prescriber is to examine the patient and decide on the

    proper treatment, order medications and follow-up.

B. Medications (other than contrast agents) will be administered by licensed healthcare providers (nurses, prescribers) within their scope of practice, following the five rights of medication administration (MCP 323.1).

C.  The Patient

1.  The patient is reassured and informed of the occurrence. The potential complications

     are discussed including, the need for immediate treatment and follow-up in the case of

     large volumes.

V. Immediate Treatment

1. Extravasation <20 ml (minor extravasation):

a)      Observation and elevation of the arm

b)      Place a cold pack intermittently on the affected site as directed by the authorized prescriber.

B. Extravasation > 21 ml (moderate extravasation):

a)  Aspirate through existing catheter prior to removal

b)  Place a cold pack intermittently on the affected site as directed by the

authorized prescriber.

            c)  Elevation of affected arm

            d) Immediate surgical consult to be obtained if the patient exhibits any of the following signs or symptoms:

1. Blistering

2. Altered tissue perfusion

3. Severe pain in the area of extravasation within 48 hours of the event

4. Change in sensation distal to the extravasation site

Vl. Follow-up Care

A. The responsible authorized prescriber scheduled on service is to evaluate the patient to determine proper follow-up care.

B. Mild or Moderate contrast extravasation:

1. The responsible staff is to document the extent of the extravasation

2. The Radiologist is to fully discuss the case with the care provider if the patient is an inpatient.

3. The patient is to be followed up by phone prn by Radiology nursing.

4. lf local reaction severely worsens, the patient is referred to Plastic Surgery for an immediate consult.

Vll. Documentation

1. The contrast extravasation should be documented in the medical record.

1.      Type and volume of contrast extravasated

2.      Specific management

2. Follow-up care and referral will be documented on a progress note and either sent to medical records or scanned into PACS or RIS in order to be added to the patient's chart

3. Complete a quality variance report and documentation in the Radiology Information        

       system and/or radiology report.