Immediate adverse reactions to intravenous iodinated contrast media in computed tomography

Business intelligence applied to the consumption of iodinated contrast agents in computed tomography scans

BACKGROUND

The management of the use of iodinated contrast agents (ICA) in the computed tomography (CT) has clinical and financial impacts; however, the approaches in the current research setting have limitations with regard to their exploration of the theme. This work describes the application of the stages of a process of business intelligence (BI), from the formulation of business questions, the building of a research database, and the adaptation of a multidimensional model, to the creation of dashboards to give support to the decision-making process in a hospital. This research aims to apply and document a BI process that provides support to the decision making of managers, so the use of ICA can be better managed, allowing for the identification of situations in which the material was wasted using a study applied to the hospital field.

METHODS

An applied exploratory research with a quantitative approach in a database made up by 24 variables and 35,388 records extracted from the RIS (Radiology Information System) that is used by the General Hospital of Porto Alegre-HCPA. The software used, supplied by AGFA Healthcare, were the Qdoc system (version 6.2.0) and the Impax BI (Version 11.1.1) for, respectively, data entry and data exploration. At the end of the process, a total of 48 variables was considered.

RESULTS

The BI process applied allowed for the identification of situations in which ICA was being wasted during the operationalization of the volume/mass ratio of the agent injected in the patient. It also offered the necessary substantiation for the managers to formulate plans, actions, and controls associated to the use of the material. This work made it possible to diminish in 15.65% the total consumption of ICA injected in the patients who underwent the CTAB1 exam (full CT scan of the abdomen), with a projected economy of US$ 10,039.95, for the performance of this exam from 2020 on. The measuring of the impact and the relevance of the process was 99.6% positive, according to the evaluation of the managers.

CONCLUSIONS

This research generated clinical and financial benefits for the HCPA, a positive evaluation by the managers and the generation of new knowledge, which can be shared with other public or private health organizations.

A systematic review of the incidence of hypersensitivity reactions and post-contrast acute kidney injury after ioversol in more than 57,000 patients: part 1-intravenous administration

OBJECTIVES

To evaluate the incidence of adverse drug reactions (ADRs), including hypersensitivity reactions (HSRs) and post-contrast acute kidney injury (PC-AKI), after intravenous (IV) administration of ioversol.

MATERIALS AND METHODS

A systematic literature search (1980-2021) of studies documenting IV use of ioversol and presence or absence of ADRs, HSRs, or PC-AKI was performed. Key information including patients' characteristics, indication and dose of ioversol, safety outcome incidence, intensity and seriousness were extracted.

RESULTS

Thirty-one studies (> 57,000 patients) were selected, including 4 pediatric studies. The incidence of ADRs in adults was reported in 12 studies from ioversol clinical development with a median (range) of 1.65% (0-33.3%), and 3 other studies with an incidence between 0.13 and 0.28%. The incidence of HSRs (reported in 2 studies) ranged from 0.20 to 0.66%, and acute events (4 studies) from 0.23 to 1.80%. Severe reactions were rare with a median (range) of 0 (0-4%), and none were reported among pediatric patients. The incidence of ADRs and HSRs with ioversol, especially those of severe intensity, was among the lowest in studies comparing different iodinated contrast media (ICM) of the same class. PC-AKI incidence was variable (1-42% in 5 studies); however, ioversol exposure per se did not increase the incidence.

CONCLUSIONS

When administered by the IV route, ioversol has a good safety profile comparable to that of other ICM within the same class, with a low incidence of severe/serious ADRs overall, and particularly HSRs. PC-AKI incidence does not seem to be increased compared to patients who did not receive ioversol. Further well-designed studies are warranted to confirm these results.

KEY POINTS

• Ioversol has a good safety profile in adult and pediatric patients when IV administered. • ADR and HSR incidence with ioversol, especially those of severe intensity, was among the lowest compared to other ICM. • IV administration of ioversol per se did not increase PC-AKI incidence.

The Ameliorative Role of Acacia senegal Gum against the Oxidative Stress and Genotoxicity Induced by the Radiographic Contrast Medium (Ioxitalamate) in Albino Rats

Arabic gum (Acacia senegal, AG) is proven effective antioxidant and cytoprotective agent. The present study was designed to test this notion by investigating the possible role of AG against the radiographic contrast medium (Ioxitalamate, Telebrix-35^®, TBX)-induced oxidative stress and genotoxicity. Albino rats were divided into four groups and supplied with either; distilled water, daily 10% (w/v) AG, an intravenous dose of TBX (1600 mg I/kg b.wt) and co-administration of TBX and AG. Rats were sacrificed and blood samples were collected to assess the genotoxicity employing the peripheral blood leucocytes fluorescent double staining; namely the acridine orange/ethidium bromide (AO/EB) staining and alkaline comet assay. Further, chromosomal analyses were done in bone marrow cells. Serum urea and creatinine levels, in addition to malondialdehyde (MDA), nitric oxide (NO), catalase (CAT) and glutathione (GSH) levels in kidney tissues were measured. Liquid chromatography-mass spectrophotometry (LC-MS-MS) was performed to identify the chemical composition of AG extract. Kidney functions, single/double-stranded DNA damage, chromosomal aberrations, mitotic index, MDA and NO levels were significantly (p < 0.001) increased in TBX-treated group compared to the control and AG-treated one. Meanwhile, CAT and GSH activities were significantly diminished and the AG supplementation significantly (p < 0.001) ameliorated these effects compared with the control and AG-treated groups. Five compounds have been identified using GNPS networking including 7,3′,4′-Trihydroxyisoflavone, Noscapine, Tetrahydropapaveroline, Costunolide, Hesperidin. In conclusion, results of the present study suggest that AG exerted a protective role against TBX-induced oxidative stress and genotoxicity which may be attributed to the active metabolites in the gum.

Acute Adverse Reactions to Nonionic Iodinated Contrast Media: A Meta-Analysis

OBJECTIVES

We aimed to meta-analytically compare the incidence of acute adverse reactions (AARs) to nonionic iodinated contrast media (ICM) according to the type of ICM in patients who underwent radiologic examinations with administration of ICM via intravascular route.

MATERIALS AND METHODS

A systematic literature search identified studies evaluating the incidence of AARs to 7 nonionic ICM (iobitridol, iohexol, iomeprol, iopamidol, iopromide, ioversol, and iodixanol) with extractable outcomes. These outcomes were pooled using a random-effects model, and the effect of ICM type on the incidence of overall and severe AARs was evaluated using meta-regression analysis.

RESULTS

Thirty studies with 1,360,488 exposures to ICM were included. The pooled incidences of overall and severe AARs to nonionic ICM were 1.03% (95% confidence interval [CI], 0.81%-1.30%; I = 0.99) and 0.0141% (95% CI, 0.0108%-0.0183%; I = 0.56), respectively. Iomeprol had the highest overall AAR incidence (1.74%; 95% CI, 0.79%-3.76%; I = 0.99), followed by iohexol (1.21%; 95% CI, 0.67%-2.17%; I = 0.99), iopamidol (1.10%; 95% CI, 0.60%-2.03%; I = 0.99), ioversol (0.88%; 95% CI, 0.43%-1.83%; I = 0.96), iodixanol (0.85%; 95% CI, 0.36%-1.95%; I = 0.99), iopromide (0.82%; 95% CI, 0.43%-1.55%; I = 0.99), and iobitridol (0.77%; 95% CI, 0.36%-1.62%; I = 0.99). Multivariable meta-regression analysis revealed that study design (P = 0.0014) and premedication (P = 0.0230) were statistically significant determinants affecting the incidence of overall AARs. Iodinated contrast media type did not affect the incidence of overall and severe AARs (P = 0.1453 and 0.4265, each).

CONCLUSIONS

The varying pooled incidences of overall and severe AARs to specific types of nonionic ICM do not remain as significant after adjusting confounders. Our results may support nonrestriction of certain types of nonionic ICM in the context of AAR avoidance.

Contrast media extravasations in patients undergoing computerized tomography scanning: a systematic review and meta-analysis of risk factors and interventions

OBJECTIVE

To identify risk factors and interventions preventing or reducing contrast medium extravasation.

INTRODUCTION

Computed tomography (CT) is a radiological examination essential for the diagnosis and monitoring of many diseases. It is often performed with the intravenous (IV) injection of contrast agents. Use of these products can result in a significant complication, extravasation, which is the accidental leakage of IV material into the surrounding tissue. Patients may feel a sharp pain and skin ulceration or necrosis may develop.

INCLUSION CRITERIA

This review considered studies that included patients (adults and children) undergoing a CT with IV administration of contrast media. The risk factors considered were patient demographics, comorbidities and medication history. This review also investigated any strategies related to: contrast agent, injection per se, material used for injection, apparatus used, healthcare professionals involved, and patient risk assessment performed by the radiology personnel. The comparators were other interventions or usual care. This review investigated randomized controlled trials and non-randomized controlled trials. When neither of these were available, other study designs, such as prospective and retrospective cohort studies, case-control studies and case series, were considered for inclusion. Primary outcomes considered were: extravasation frequency, volume, severity and complications.

METHODS

The databases PubMed, CINAHL, Embase, the Cochrane Register of Controlled Trials, Web of Science PsycINFO, ProQuest Dissertations and Theses A&I, TRIP Database and ClinicalTrials.gov were searched to find both published and unpublished studies from 1980 to September 2016. Papers were assessed by two independent reviewers for methodological validity using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Data were extracted using the standardized data extraction tool from JBI SUMARI. In one case, quantitative data from two cohort studies were pooled in a statistical meta-analysis. However, generally, statistical pooling was not possible due to heterogeneity of the interventions, populations of interest or outcomes. Accordingly, the findings have been presented in narrative form.

RESULTS

Fifteen articles were selected from a total of 2151 unique studies identified. Two were randomized controlled trials and 13 were quasi-experimental and observational studies. The quality of these studies was judged to be low to moderate. Some patient characteristics, such as female sex and inpatient status, appeared to be risk factors for extravasation. Additionally, injection rate, venous access site and catheter dwelling time could affect the volume extravasated. Preliminary studies seemed to indicate the potential of extravasation detection accessories to identify extravasation and reduce the volume extravasated. The other interventions either did not result in significant reduction in the frequency/volume of extravasation, or the results were mixed across the studies.

CONCLUSIONS

The majority of the studies included in this review evaluated the outcomes of extravasation frequency and volume. Given the quality of the primary studies, this systematic review identified only potential risk factors and interventions. It further highlighted the research gap in this area and the importance of conducting trials with solid methodological designs.

Acute kidney injury after contrast-enhanced examination among elderly

OBJECTIVES

to assess renal function in elderly patients undergoing contrast-enhanced computed tomography and identify the preventive measures of acute kidney injury in the period before and after the examination.

METHOD

longitudinal cohort study conducted at the Federal University of São Paulo Hospital, from March 2011 to March 2013. All hospitalized elderly, of both sexes, aged 60 years and above, who performed the examination, were included (n=93). We collected sociodemographic data, data related to the examination and to the care provided, and creatinine values prior and post exam.

RESULTS

an alteration in renal function was observed in 51 patients (54%) with a statistically significant increase of creatinine values (p<0.04), and two patients (4.0%) required hemodialysis.

CONCLUSION

There is an urgent need for protocols prior to and post contrast-enhanced examination in the elderly, and other studies to verify the prognosis of this population.

Evaluation of the mutagenic effect of the iodinated contrast medium Urografina® 292 using the micronucleus test in mouse bone marrow cells

Contrast media (CM) are frequently used in diagnostic radiology and in radiotherapy as a diagnostic tool and in treatment planning. Previous studies have demonstrated that these compounds induce chromosomal aberrations. This study evaluates the mutagenic effects induced by the contrast medium Urografina® 292 (meglumine amidotrizoate and sodium-ionic dimmer) in bone marrow cells (BMC) of mice in vivo. Micronuclei assay was performed in BMC of CF-1 mice injected with CM 1.5 and 3.0 mL/kg intravenous doses and 1.0, 2.0, 3.0 mL/kg intraperitoneal doses. The animals were beheaded 24 h after treatment by cervical dislocation, and femur BMC from each animal were used in the micronucleus test. The group treated with the highest intravenous injection of Urografina® 292 (3.0 mL/kg) presented an increase in the frequency of micronucleated polychromatic erythrocytes (MNPCEs) in relation at the control group (P<0.05). The results obtained after intraperitoneal administration of CM showed that all doses (1.0 mL/kg, 2.0 mL/kg and 3.0 mL/kg) increased the frequency of MNPCEs, being significantly different from the negative control (P< 0.01). The present results suggest that iodinated contrast media Urografina® 292 may cause a significant increase of cytogenetic damage in bone marrow cells of mice.

The Role of 3 Tesla MRA in the Detection of Intracranial Aneurysms

Intracranial aneurysms constitute a common pathological entity, affecting approximately 1–8% of the general population. Their early detection is essential for their prompt treatment. Digital subtraction angiography is considered the imaging method of choice. However, other noninvasive methodologies such as CTA and MRA have been employed in the investigation of patients with suspected aneurysms. MRA is a noninvasive angiographic modality requiring no radiation exposure. However, its sensitivity and diagnostic accuracy were initially inadequate. Several MRA techniques have been developed for overcoming all these drawbacks and for improving its sensitivity. 3D TOF MRA and contrast-enhanced MRA are the most commonly employed techniques. The introduction of 3 T magnetic field further increased MRA's sensitivity, allowing detection of aneurysms smaller than 3 mm. The development of newer MRA techniques may provide valuable information regarding the flow characteristics of an aneurysm. Meticulous knowledge of MRA's limitations and pitfalls is of paramount importance for avoiding any erroneous interpretation of its findings.

[New nursing diagnoses in imaging: submission to NANDA International]

The present work reports the experiment on the creation and submission to North American Nursing Diagnosis Association International (NANDA-I) of Nursing Diagnosis in the imageology area: "Adverse Reaction to Iodinated Contrast Media" and "Risk of Adverse Reaction to Iodinated Contrast Media". For this experiment the method of integrative revision of literature was utilized associated with the experience in clinical practice. The document for submission was elaborated according to guidance offered by NANDA-I and sent for appreciation to the Diagnosis Development Committee. The risk diagnose was approved and the real diagnose is still in evaluation process by the Diagnosis Development Committee. With this experiment we hope to motivate Brazilian nurses to contribute to the taxonomy of NANDA-I and participate in the building ofnursing knowledge.

Diagnosis of unruptured intracranial aneurysms: 3T MR angiography versus 64-channel multi-detector row CT angiography

BACKGROUND AND PURPOSE

We compared 3-dimensional time-of-flight magnetic resonance angiography (3D TOF MRA) using a 3-tesla (T) MR unit with 64-channel multi-detector row computed tomographic angiography (64-MDCTA) for detection and characterization of angiographically proven unruptured intracranial aneurysms.

METHODS

Thirty-eight patients with 47 aneurysms and 8 patients without aneurysms underwent 3T, 3D TOF MRA; 64-MDCTA; and intra-arterial angiography. As a first study, 3 radiologists blinded to pertinent clinical information independently reviewed MRA and CTA images. We evaluated diagnostic accuracy using an alternative free-response receiver operating characteristic (AFROC) analysis and evaluated the sensitivity and specificity of each technique. Next, 2 radiologists used volume-rendering images generated from MRA or CTA data to evaluate the morphology of the 47 aneurysms detected, and MRA and CTA results were compared. Three-dimensional digital angiography (DA) images were used as the standard of reference.

RESULTS

On the AFROC analysis, the value of the mean area under the AFROC curve (A(1)) was 0.91 for both modalities. Mean sensitivity of 89% and specificity of 76% for MRA were not significantly different from sensitivity of 87% and specificity of 79% for CTA. Therefore, when used to evaluate aneurysmal morphology, both modalities appear satisfactory for determining these vascular anomalies.

CONCLUSION

Three-tesla, 3D TOF MRA and 64-MDCTA are excellent modalities with high diagnostic accuracy for evaluating unruptured intracranial aneurysms and no significant difference between them in diagnostic performance.

Cuidados de enfermagem na prevenção da insuficiência renal provocada por contraste após cateterismo

O estudo teve como objetivo identificar produções científicas de enfermagem sobre insuficiência renal aguda provocada por contraste iodado após cateterismo cardíaco, no período de 2002 a 2007, analisando sua aplicabilidade à prática. Foi realizada ainda uma análise crítica das produções científicas selecionadas, delineando os cuidados de enfermagem. Este estudo é uma pesquisa bibliográfica de artigos de enfermagem, encontrados através de busca computadorizada. Dos 47 artigos encontrados, 10 foram selecionados por terem atendido os critérios de inclusão. Após a análise dos artigos, verificamos a importância da atuação do enfermeiro na prevenção da insuficiência renal aguda provocada por contraste. Além disso, evidenciamos a melhor prática de enfermagem para a prevenção da insuficiência renal aguda provocada por contraste.