do we treat contrast extravasation when it happens?

Part 1: How do we treat contrast extravasation when it happens? Part 2: Is cold compresses the rule or hot compresses?

Part 1: The key is rapid detection and rapid intervention. The procedures we follow depend on the size of the extravasation, the site of injection and our assessment of the patients injection site. Some rules are listed on the next few slides. Part 2: Although either can be used we favor extremity elevation and cold packs for treatment IV Contrast Extravasation Management What do you do? Who do you call? What are key parameters in patient management? When do you need to call plastic surgery (or a surgeon)? "Extravasation of CT scan contrast media into upper extremity subcutaneous tissue is a relatively frequent complication of injection. Potential sequelae of extravasation include compartment syndrome, skin sloughing, and necrosis. Many institutions institute protocols requiring inpatient plastic surgery consultations immediately following extravasation injury to the upper extremity. We hypothesize that conversion to non-ionic contrast media for contrast CT studies has greatly reduced the incidence of severe extravasation injuries, and may alleviate the need for routine hand surgery consultations." CT contrast extravasation in the upper extremity: strategies for management.  Sbitany H et al. Int J Surg. 2010;8(5):384-6. "Extravasation of non-ionic CT contrast media appears to be innocuous and can be treated with conservative therapy. Plastic surgery consultation should be obtained when there are obvious signs of skin and soft tissue compromise or symptoms of compartment syndrome." CT contrast extravasation in the upper extremity: strategies for management. Sbitany H et al. Int J Surg. 2010;8(5):384-6. "Surgical consultation prior to discharge should be obtained whenever there is concern for a severe extravasation injury. An immediate surgical consultation is indicated for any patient in whom one or more of the following signs or symptoms develops: progressive swelling or pain, altered tissue perfusion Òas evidenced by decreased capillary refill at any time after the extravasation has occurred, change in sensation in the affected limb, and skin ulceration or blistering. It is important to note that initial symptoms of a compartment syndrome may be relatively mild (such as limited to the development of focal paresthesia)." ACR Manual on Contrast Media Version 9 (2013) "In 102 consecutive cases, immediate surgical therapy was necessary in 0. Non-ionic medium was used in 94% of these cases, and ionic dye was used in 6%. Extravasation of less than 100 cc occurred in 90%, and only 10% were greater. Plastic surgery consultation was immediately obtained in 42% of cases. Factors prompting consultation included extravasation >30 cc, and the presence of erythema or induration. Trends for consultation remained without discernable pattern when patients were stratified by age, amount of extravasate, or anatomic location. Conservative management was recommended in all cases." CT contrast extravasation in the upper extremity: strategies for management. Sbitany H et al. Int J Surg. 2010;8(5):384-6. ESUR Guidelines on Contrast Media Conservative management is adequate in most cases limb elevation apply ice packs careful monitoring If a serious injury is suspected, seek the advice of a surgeon. ESUR Guidelines on Contrast Media This publication by the ESUR is well done and similar in many ways to the ACR 9.0 manual Well worth reading http://www.esur.org/guidelines/ "For soft-tissue extravasation of IV contrast media, 95% elevate the affected extremity, 76% use ice and 45% use heat." Practice Patterns for the Use of Iodinated IV Contrast Media for Pediatric CT Studies: A Survey of the Society for Pediatric Radiology Callahan MJ et a. AJR 2014;202:872-879 "Ninety five percent of our responders elevate the affected extremity after soft tissue extravasation, which decreases capillary hydrostatic pressure and promotes resorption. There is no clear evidence to favor the use of ice or heat compresses." Practice Patterns for the Use of Iodinated IV Contrast Media for Pediatric CT Studies: A Survey of the Society for Pediatric Radiology Callahan MJ et a. AJR 2014;202:872-879