IV Contrast Extravasation PQI Project Feed-Back Document
from the
Society of Abdominal Radiology & American College of Radiology
This performance feedback document and the accompanying spreadsheet include summaries of the information you submitted to the ACR National Radiology Data Registry (NRDR) for the SAR-ACR IV Contrast Extravasation PQI project. There is also information comparing your performance with national benchmarks and educational information from established guidelines found in the radiology literature. These feedback documents should be reviewed by each radiologist participating in this PQI project and also reviewed as a group. It is your responsibility to review this material and assess your performance in this important area of patient safety.
Following review of this information, if your group feels there are areas needing improvement, then you should develop, document and implement a plan for improvement. Once that plan has been implemented, a repeat cycle of submitting data from extravasation events to the ACR-NRDR must be done. You will again receive feedback documents for your group to assess whether the improvement plan had any beneficial impact. This process of performance data submission, feedback with comparison to benchmarks/established guidelines, implementation of improvement plans, and re-measuring performance is the backbone of all PQI projects.
Once your group has decided that your performance in this area is optimized, you may elect to terminate this PQI project and select other projects for quality improvement.
Participating Institution or Group: ACR Test
Dates of Data Collection & Submission: 10/08/2009 - 04/06/2010 Total Number of Contrast Extravasation Events Reported: 1
# of Contrast Enhanced CT Injections during Reporting Period: 752
Contrast Extravasation Rate (Extravasation Events/# Contrast Enhanced CT Injections): 0.1 %
American College of Radiology - National Radiology Data Registry (NRDR)
A multi-institutional registry of over 30 radiology practices within the United States retrospectively reported 568 extravasation events out of 236,688 contrast enhanced CT scans yielding an extravasation rate of 0.24%. The range of extravasation rates for these practices was from 0.06% to 0.91% [NRDR]. This is similar to literature reporting the contrast extravasation rate between 0.1 to 0.9% [1, 2].
Patient age, gender and health status: Patient age and health status are important considerations when assessing the risk of contrast extravasation. Communication with the patient before and during the exam may reduce the risk of contrast extravasation. Infants, young children, unconscious and debilitated patients are at increased risk for contrast extravasation injury because they are unable to complain of pain at the injection site [1, 4]. In children, the volume of extravasated material necessary to cause tissue damage is smaller than for adults [3].
CONTRAST
Contrast type, injection method and injection rate: The incidence of contrast extravasation is higher with mechanical injection than with hand injection technique [4]. There is, however, no evidence for an increased risk of extravasation with higher mechanical injection rates compared to lower mechanical injection rates [1, 4, 6].
Low osmolar contrast agents (LOCM) are better tolerated than high osmolar contrast agents (HOCM) in the event of a contrast extravasation [1]. There is no published evidence that one type of contrast agent is more likely to result in extravasation than another type.
CATHETER
Catheter gauge, type of catheter, and location of catheter: The cannula size and type should be appropriate for the rate of injection. A 20G catheter should be used for injection rates greater than 3 mL/sec [1]. A flexible, plastic IV cannula is preferred over a metal needle as extravasations occur more commonly with metal needles than with plastic IV cannulas [1, 4].
Many central venous catheters can be mechanically injected, but a scout topogram or recent chest x-ray should be reviewed to confirm proper position of the catheter. Similar to peripheral IV catheters, venous backflow should be documented before initiating an injection. If venous backflow cannot be confirmed, then a hand injection of saline should be attempted and if there is any resistance to flow or the patient develops discomfort, the injection should be stopped. Generally, 9.5F to 10F central venous catheters can be injected up to 2.5 mL/sec safely [1]. Many peripherally inserted central catheters (PICC) can also be mechanically injected. Generally 1 mL/sec is safe in most PICC catheters [1].
Antecubital or large forearm veins are preferred for venous access for IV injections of contrast. If a hand or wrist vein must be used, then injection rates should be no greater than 1.5 mL/sec [1]. Injections through a catheter located in the hand are frequently associated with extravasation injury [4]. Also, ankle and foot injections have a higher risk of extravasation [1]. In one large retrospective study most extravasation events occurred in injections not in the antecubital fossa [2].
Catheter placed by radiology: In one series, 40% of extravasation events occurred when
indwelling IV lines were used [4]. IV catheters that have been in place more than 24 hours have an increased risk of extravasation [1]. It is important to check how long a pre-existing IV line has been in place and to be certain that it is functioning before injecting iodinated contrast through the line. Also, backflow of blood should be checked before initiating an injection and if no backflow can be
confirmed, then a test injection with saline with careful monitoring of the injection site should be done [1]. Venipuncture sites that appear infiltrated or inflamed should not be used for contrast injection [1].
Extravasation Detection Device or Accessory: Devices that detect extravasation have sensitivity of 100% and specificity of 98% for clinically relevant extravasations (> 10mL) [4, 5]. These extravasation detection devices (EDAs) are pliable, adhesive-backed electrode patches placed just above the IV cannula tip and are connected to an EDA processing module attached to the power injector. This electrode patch detects changes in skin electrical impedance that occurs with contrast extravasation and can be calibrated to detect extravasations as small as 10 mL and suspend injection before 20 mL has extravasated. Set up of this device takes less than 20 seconds. In one study of 500 injections, there were no false-negative results and 12 false-positive results (9 of the 12 false-positive were thought to be due to inadvertent manipulation of the electrode patch during injection) [5].
Regardless of whether an extravasation detector device is used or not, close visual inspection of the injection site should be performed during the first 15 seconds of an injection and the injection should be stopped if there is visible swelling or discoloration, or the patient complains of pain or burning [1]. ESTIMATED CONTRAST VOLUME EXTRAVASATED
< 10mL = 0.0 % of extravasation events reported 10-49mL = 100.0 % of extravasation events reported 50- 99 mL = 0.0 % of extravasation events reported > 99 mL = 0.0 % of extravasation events reported
American College of Radiology - National Radiology Data Registry (NRDR)
A multi-institutional registry of over 30 radiology practices within the United States retrospectively reported 568 extravasation events out of 236,688 contrast enhanced CT scans. The estimated volume of
extravasation was less than 10 mL in 5.8%, 10-49 mL in 55.1%, 50-99 mL in 26.7%, and ≥ 100 mL in 12.4% [NRDR].
CONTRIBUTING FACTORS IN AN EXTRAVASATION EVENT
In addition to patient age and ability to communicate discussed above, there are many patient conditions that predispose to an increased risk for contrast extravasation and resultant injury. Knowledge of these conditions will help your CT technologists identify those patients that may need extra care and observation during the injection.
1. Patients that are receiving chemotherapy have higher risk because of increased fragility of the vein wall [4]
2. Patients that have had multiple venipunctures in the same vein [4] 3. Patients with low muscle mass and atrophic subcutaneous tissue [4]
4. Patients with arterial insufficiency or compromised venous/lymphatic drainage are less able to tolerate extravasation injury [1, 4]
INITIAL INTERVENTIONS
There is no consensus about the best approach for management of contrast extravasation injuries. Generally, the following guidelines are probably useful [1, 4]
1. Observation of the patient. The radiologist should release the patient only if the signs and symptoms have improved during the observation period (generally 2-4 hours) [1].
2. Elevation of the affected extremity [1] 3. Application of hot or cold compresses [1]
4. Hyaluronidase injection into the extravasation site (conflicting evidence of the usefulness of this therapy)
5. Aspiration of fluid from the extravasation site is controversial because usually only a small amount of fluid can be recovered and this adds a risk of introducing infection.
6. Documentation of the event in the medical record and notification of the referring provider.
Most plastic surgeons believe that the majority of extravasation injuries can be handled conservatively [4, 7]. Occasionally, severe skin ulceration can occur even with small quantities of extravasation, even as small as 10mL [4]. The severity and prognosis of an extravasation event is difficult to determine at initial evaluation, thus close clinical follow-up for several hours is necessary [1]. INITIAL SIGNS AND SYMPTOMS OF EXTRAVASATION
When extravasation occurs, many patients will complain of stinging or burning at the injection site. However, sometimes patients will experience no signs or symptoms [1, 4]. The extravasation site can appear red, swollen and be tender [4].
Indications that a severe extravasation injury has occurred that would require surgical consultation for management include [4]
1. Skin blistering
2. Altered tissue perfusion 3. Paresthesias
4. Persistent or increasing pain after 4 hours of observation
5. Development of compartment syndrome (enlargement of the extremity with a tense, dusky appearance or diminished arterial pulses)
6. Surgical consultation is probably necessary if 50 mL of HOCM or 100 mL of LOCM is estimated to have extravasated in a forearm or antecubital vein. Smaller amounts are of concern if the injection was in the hand, wrist, foot or ankle [1].
Mechanisms for injury related to contrast extravasation include the osmolality of the contrast agent, direct cytotoxicity, and mechanical compression by the extravasated contrast resulting in a
extravasated contrast, but even small extravasation events (less than 15mL) have caused skin ulcerations [4].
OUTCOME
Most extravasation injuries resolve within 2-4 days [4]. The acute, local inflammatory response to an extravasation of contrast will peak in 24 to 48 hours. Ulceration and tissue necrosis can be identified as early as 6 hours after the injury [1].
ASSESSMENT OF SEVERITY OF EXTRAVASATION INJURY
1. Mild extravasation injuries are those in which signs and symptoms are absent or consisted of pain, swelling, or mild erythema. These signs and symptoms resolved with limited treatment and with no long term effects [2].
2. Moderate extravasation injuries include those where the presenting signs and symptoms include moderate to severe erythema, blistering, marked pain or swelling, or injuries in which additional treatment was instituted regardless of the initial signs and symptoms. All signs and symptoms of moderate injuries, however, resolve within 2 weeks of the injury [2].
3. Severe extravasation injuries either produce long-term adverse effects (more than 2 weeks) such as pain, swelling and limitations in extremity movement, or required surgical intervention [2].
Minor extravasation = 0.0 % of extravasation events reported Moderate extravasation = 0.0 % of extravasation events reported Severe extravasation = 100.0 % of extravasation events reported
American College of Radiology - National Radiology Data Registry (NRDR)
A multi-institutional registry of over 30 radiology practices within the United States retrospectively reported 568 extravasation events out of 236,688 contrast enhanced CT scans. 95% of extravasations were
considered minor, 4.5% moderate and 0.5% severe. [NRDR].
LITERATURE REFERENCES
1. American College of Radiology Manual on Contrast Media, Version 5.0 (2006).
2. Wang CL, Cohen RH, Ellis JH, Adusumilli S, Dunnick NR. Frequency, Management, and Outcome of Extravasation of Nonionic Iodinated Contrast Medium in 69,657 Intravenous Injections. Radiology 2007; 243:80-87
3. Amaral JG, Traubici J, BenDavid G, Reintamm G, Daneman A. Safety of Power Injector Use in Children as Measured by Incidence of Extravasation. AJR 2006; 187:580-583
4. Bellin M, Jakobsen JÅ, Tomassin I, Thomasen HS, Marcos SK. Contrast Medium Extravasation Injury: Guidelines for Prevention and Management. European Radiology 2002(12):2807-2812
Evaluation in 500 Patients. Radiology 1999; 212:431-438
6. Jacobs JE, Birnbaum BA, Langlotz CP. Contrast Media Reactions and Extravasation: Relationship to Intravenous Injection Rates. Radiology 1998; 209:411-416
7. Federle MP, Chang PJ, Scharmen C, Ozgun B. Frequency and Effects of Extravasation of Ionic and Non-ionic CT Contrast Media during Rapid Bolus Injection. Radiology 1998; 206:637-640
