Contrast media

Contrast media are chemical substances used in medical imaging to improve the visualization of internal
body structures in X-Ray based CT, fluoroscopy or in MRI.

The basic principle is that contrast agents are administered in such a way as to alter the absorption of x-
rays by specific anatomic structures in relation to their surroundings. Contrast agents may be positive
(iodine or barium compounds, for example), or negative (gases).

Most IV contrast ontain iodine which has atomic number 53 and atomic weight 127.

Iodene is preferred because

- High contrast density due to high atomic number

- Firm binding to variable benzene ring
- Low toxicity.

WATER SOLUBLE IODINATED CONTRAST MEDIA.

They are broadly classified as

High osmolar
IONIC MONOMER- Diatrizoic acid, iodamic acid, ioglicic acid, iothalamic acid, ioxithalamic acid
Low osmolar
IONIC DIMER - ioxaglic acid, iocarmic acid
NON-IONIC MONOMER- iohexol,iopamidol,ioversol,iopromide,iopentol
NON-IONIC DIMER- iotrol,iotrolan,iodixanol.

High osmolar (IONIC MONOMER)

Extremely high osmolar concentration ..up to 8 times of physiological level (300mosm/kg water).
Causes osomlar challenge to every cell of body
Radio-opacity is dependent upon iodine atoms in contrast (in conventional CM iodine particle ratio is
3:2).
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Proprties of ideal contrast media
 1. High water solubility
2. Heat and chemical stability (shelflife 3-5 yrs)
3. Biologically inert
4. Low viscosity
5. Low or iso-osmolar to plasma
6. Selective excretion (renal)
7. Cheap
8. High lethal dose
9. Low effective dose

IONIC Contrast Media Non- IONIC Contrast Media

Ionic contrast media breaks down into cations and
inions. When these cations and anions enters
blood they cause increase in osmolarty.
For every 3 iodene molecule present in ionic CM 1
cation and 1 anion is produced.
Do not dissociate into charged particles on
entering blood.
For every 3 iodene molecule 1 neutral molecule is
produced

IONIC CM therefore is 3:2 compound NON-IONIC CM therefore is 3:1 compound

MONOMER DIMER

Contain only single benzene ring 2 Benzene rings combined to produce a dimer,
Iodine particle ratio 3:1 Deliver more iodine with each molecule of
contrast.

Iodene particle ratio 6:1

Physiology of CM:
After IV injectiondiffuse into extravascular space. Plasma half life is 30-60 min.
Filetered into bowmans capsule by passive glomerular filteration.
In PCT reabsorption of Na and H2O causes 5-10 times concentration of contrast media.
Further concentration occurs by counter current mechanism in loop of henle and by ADH in DCT.

Adverse Reactions :

1- Reactions unrelated to contrast media

a. Pyrogenic (Unsterile injection)
b. Vasovagal reaction specially in anxious patients.
 c. Hypertension in pts with pheochromocytoma
d. Dehydration
e. Hypoglycemia.

2. Adverse effects related to hyperosmolarity.

a) Capillary Endothilial damage

b) Haemolysis
c) Vasodilation
d) Hypervolumia
e) CVS effects
f) Pulmonary edema
g) Thrombosis and trombophlebitis
h) Disturbance in blood brain barrier

3. Chemotoxic acion:

Chemotoxic effects are usually due to cations. Especially Na. The effects are seen in
a. Neurons
b. Myocardial cells
c. Capillary endothelium
d. RBC
e. Kidney

4. Immunological Toxicity (Allergic)

* Activation of complement/kinins/ coagulation/fibrinolytic systems

* Increased Bradykinin
* Inhibition of cholinesterase increase acetylcholine bradycadria, bronchospasm, collape
* Release oof histamine /bradykinin/serotonin
Anphylactic reaction in previously sensitized individuals
Anaphylactoid reaction previously non-sensitized individuals

High risk group for allergic adverse reactions

1. Asthma
2. h/o allergy
3. h/o prior reacton to contrast
4. Cardiovascular diseases
5. Diabetes
6. Old/ neonates
 7. Myelomatosis, polycythemia
8. Sickle cell anemia, pheochromocytoma, homocystinuria

Premedicatons in hgh risk group

Steroids/antacids/ sos hydrocort

-Minor reaction (5%) : Nausea, vomiting, mild rash, headache, mild dyspnoea.--- > no
treatment/symptomatic/ reassurance
-Intermediate reaction (1%) : extensive urticaria, facial edema, bronchospasm, laryngeal edema,
dyspnoea, chest pain, mild hypotensin. Treatment depending upon manifestations
- Severe reactions (0.0025% )

Treatment of allergic reaction

ABC
Oxygen
SOS Assisted ventilation
Epinephrineperipheral vasoconstriction- effective in hypotension
Bronchodilation
Increase cardiac contractility
0.1-0.3ml SC/IM repeat every 10-15 min

Corticosteroids:
IVF:
Antihistamincs:
Laryngeal edema- epinephrine/o2 / intubate SOS
Bronchospasm : O2/ Aminophylline/Epinephrine
Pulmonary edema : Elevate head end/ O2/Lasix/morphine/Hydrocort/ICU care
Hypotension: Elevate leg end/ O2/IVF/Atropine/Epinephrine
Seizures : Anticonvulsants/O2/Turn to side
Hypertension : O2/NTG/Nifedipine/ECG/Phentolamine if pheochromocytoma/ Furosemide
Treatment of Extravasation of contrast media
1: elevate affected limb.
2. Ice packs
3. Plastic surgery SOS
4. Close follow up

Nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD)[1] is a rare

and serious syndrome that involves fibrosis of skin, joints, eyes, and internal organs. The first cases
were identified in 1997 and its cause is not fully understood. However, evidence suggests NSF is
associated with exposure to gadolinium (with gadolinium-based MRI contrast agents being
frequently used as contrast agents for magnetic resonance imaging (MRI)) in patients with
severe kidney failure.[2] Epidemiological studies suggest that the incidence of NSF is unrelated to
gender, race, or age and it is not thought to have a genetic basis. A registry for NSF has identified
about 335 cases as of 2011.[3]
Most patients with NSF have undergone hemodialysis for kidney failure, some have never
undergone dialysis and others have received only peritoneal dialysis. Many people with NSF have
taken immunosuppressive medications and have other diseases, such as hepatitis C. Four of the
seven gadolinium contrast agents approved by the U.S. Food and Drug Administration have been
principally implicated in NSF, including gadodiamide, gadopentetate,
and gadoversetamide. Gadobenate has also been associated with NSF, but further research has
shown that gadobenate diglumine might be safe even in patients undergoing dialysis. [4]

Iodinated contrast media exposure may be associated with development of either

hyperthyroidismorhypothyroidism,presumablyduetotheeffectoffree,biologically
activeiodideionspresentinthecontrastmediapreparation.Itispossiblethatlongterm
storageandexposuretolightmayleadtophotolyticdegradationofcontrastmediaand
henceanincreasedconcentrationoffreeiodineinsolution[8].

Theuseofcontrastmediamayleadtokidneydysfunction,especiallyinpatientswith
preexistingrenalimpairmentandinthosewithdiabetes.Contrastinducednephropathy
(CIN)orcontrastinducedacutekidneyinjury(CIAKI)isthereforeaniatrogenicdisease
andhasbecomeasignificantsourceofhospitalmorbidityandmortality.Severalyears
agoitwasindicatedasthethirdleadingcauseofhospitalacquiredacuterenalfailure
(aftersurgeryandhypotension)accountingfor12%ofallcases[23].Ithasbeenstated
thatitoccursinupto5%ofhospitalizedpatientswhoexhibitnormalrenalfunctionprior
tointroductionofcontrast[24].Foroutpatients,theriskforCIN,particularlyinpatients
with creatinine clearance >45mL/min per 1.73m 2, seems to be extremely low
(approximately2%)[25].IthasbeenstatedthatCINisnotcommoninpatientswith
normalpreexistingrenalfunction;rather,itoccursmorefrequentlyinpatientswithrenal
impairment and is possibly exacerbated when the impairment is due to diabetic
nephropathy[26].