Adverse reactions to intravenous pyelography in children

Pediatric providers and radiology examinations: knowledge and comfort levels regarding ionizing radiation and potential complications of imaging

BACKGROUND

Pediatric providers should understand the basic risks of the diagnostic imaging tests they order and comfortably discuss those risks with parents. Appreciating providers' level of understanding is important to guide discussions and enhance relationships between radiologists and pediatric referrers.

OBJECTIVE

To assess pediatric provider knowledge of diagnostic imaging modalities that use ionizing radiation and to understand provider concerns about risks of imaging.

MATERIALS AND METHODS

A 6-question survey was sent via email to 390 pediatric providers (faculty, trainees and midlevel providers) from a single academic institution. A knowledge-based question asked providers to identify which radiology modalities use ionizing radiation. Subjective questions asked providers about discussions with parents, consultations with radiologists, and complications of imaging studies.

RESULTS

One hundred sixty-nine pediatric providers (43.3% response rate) completed the survey. Greater than 90% of responding providers correctly identified computed tomography (CT), fluoroscopy and radiography as modalities that use ionizing radiation, and ultrasound and magnetic resonance imaging (MRI) as modalities that do not. Fewer (66.9% correct, P<0.001) knew that nuclear medicine utilizes ionizing radiation. A majority of providers (82.2%) believed that discussions with radiologists regarding ionizing radiation were helpful, but 39.6% said they rarely had time to do so. Providers were more concerned with complications of sedation and cost than they were with radiation-induced cancer, renal failure or anaphylaxis.

CONCLUSION

Providers at our academic referral center have a high level of basic knowledge regarding modalities that use ionizing radiation, but they are less aware of ionizing radiation use in nuclear medicine studies. They find discussions with radiologists helpful and are concerned about complications of sedation and cost.

Incidence and Risk Factors for Gadolinium-Based Contrast Agent Immediate Reactions

Since their clinical introduction in 1988, gadolinium-based contrast agents (GBCAs) have demonstrated an excellent safety profile with a reported acute adverse reaction rate ranging from 0.01% to 2%. By comparison, the acute adverse reaction rate of low osmolar nonionic computed tomography contrast agents (CTCs) ranges from 0.7% to 3.1%. Many of the risk factors associated with CTC reactions (drug allergies, asthma, atopy, prior contrast reaction) also point toward an increased incidence of acute adverse events to GBCAs. With CTCs, an increased adverse event rate was associated with ionic preparations and high osmolality. In response to concerns for nephrogenic systemic fibrosis, GBCAs are now selected for their augmented chemical stability. These agents possess some combination of macrocyclic chelates or ionic preparations. With their improved chemical stability, these agents also possess higher osmolality and the increased potential to elicit an acute adverse reaction. In light of these concerns, researchers are now focusing greater efforts on reexamining acute adverse reactions to GBCAs and whether there is an increased association with certain agents. In addition to hypersensitivity reactions, this article will also discuss contrast extravasations, safety of GBCAs for pregnant and nursing patients, and the potential nephrotoxic effects of GBCAs.

Safety first: Recognizing and managing the risks to child participants in magnetic resonance imaging research

Specialized and up-to-date knowledge is required to identify and manage the risks associated with advanced biomedical research. Additional complexities need to be considered when the research involves infants or young children. In this article, we focus on recent information about the physical risks of pediatric magnetic resonance imaging research and highlight information gaps. With an eye to assisting institutional review boards and researchers, we consider strategies for the management of these risks and formulate key questions aimed at exposing hidden hazards. Institutional review boards should ask these questions, and researchers should bear them in mind as they develop research protocols.

Frequency and severity of acute allergic-like reactions to gadolinium-containing i.v. contrast media in children and adults

OBJECTIVE

The purpose of our study was to determine the frequency and severity of acute allergic-like reactions to i.v.-administered gadolinium-containing contrast media in children and adults.

MATERIALS AND METHODS

Pediatric (younger than 19 years) and adult department of radiology contrast material reaction forms involving patients who experienced acute allergic-like reactions to gadolinium-containing contrast media from January 1, 2001, through December 31, 2006, were retrospectively evaluated for the specific types of acute allergic-like reactions, reaction management, and patient outcomes. Relevant patient medical information, including documentation of prior gadolinium- or iodine-containing contrast material reaction, premedication before acute allergic-like reaction to i.v. gadolinium-containing contrast material, previous allergic reactions to substances other than contrast media, and history of asthma, was obtained by reviewing electronic medical records.

RESULTS

Seventy-eight thousand three hundred fifty-three (65,009 adult and 13,344 pediatric) i.v. administrations of gadolinium-containing contrast material were performed during the study period. Acute allergic-like reactions were documented after 54 injections (reaction frequency, 0.07%). Forty-eight reactions involved adult patients (adult reaction frequency, 0.07%), and six reactions occurred in pediatric patients (pediatric reaction frequency, 0.04%). Forty (74%) acute allergic-like reactions were mild, 10 (19%) were moderate, and four (7%) were severe. No gadolinium-containing contrast material-related death occurred during the study period. Twenty-six (50%) of 52 patients had one or more presumed risk factors for contrast material reaction.

CONCLUSION

Adult and pediatric acute allergic-like reactions to i.v.-administered gadolinium-containing contrast media are rare. Most of these reactions are mild; however, moderate and severe reactions that require immediate management do occur.

Incidence and severity of acute allergic-like reactions to i.v. nonionic iodinated contrast material in children

OBJECTIVE

The purpose of this study was to evaluate the incidence and severity of acute allergic-like reactions related to i.v. administration of low-osmolality nonionic iodinated contrast material in children.

MATERIALS AND METHODS

Department of radiology contrast material reaction forms involving pediatric (younger than 19 years) imaging examinations performed from January 1, 1999, through June 30, 2006, were retrospectively evaluated for type of acute allergic-like reaction, severity of reaction, and patient outcome. The electronic medical record was reviewed for pertinent medical history related to each acute reaction, including previous contrast material reaction, premedication before administration of i.v. iodinated contrast material, previous allergic-like reaction to substances other than contrast material, and history of asthma.

RESULTS

In our department during the time period specified, 11,306 pediatric i.v. administrations of low-osmolality nonionic iodinated contrast material were performed. Acute allergic-like reactions to the contrast material were documented in 20 (0.18%) of the patients. Sixteen (80%) of the acute allergic-like reactions were categorized as mild, one (5%) as moderate, and three (15%) as severe. No deaths were attributed to i.v. nonionic iodinated contrast material. Six (30%) of the patients had a history of allergic-like reaction, including two patients who had a history of reaction to iodinated contrast material. Five (25%) of the patients had a history of asthma.

CONCLUSION

Acute allergic-like reactions to i.v. administration of low-osmolality nonionic iodinated contrast material in children are rare. As in the adult population, most pediatric reactions are mild; however, severe reactions do occur.

[Primary vesicoureteral reflux treatment in childhood: comparsion of two systematic review]

Many medical practices are being carried out unawares of their efficiency, or of their actual impact on the health of the patients, therefore it is necessary to consider the support of professional recommendations with scientific evidence.

THE PRIMARY OBJECTIVE

To perform a systematic review (SR) of the therapeutic management of primary VUR in pediatric urology.

MATERIAL AND METHODS

A systematic review has been performed, including scientific evidence-based medicine criteria, of the articles published in all of the available databases. Inclusion criteria concerning basic quality of the articles were considered essential, as well as exclusion criteria to be able to reject the articles.

RESULTS AND DISCUSSION

Subsequently, and following the critic reading of greater than 320 articles, statistical study of the grouped data was performed according to the type of treatment and to the benefits contributed by each treatment, and also to their undesirable effects. Finally we have made a comparison between our results and recent Cochrane Systematic Review. The following Conclusions were drawn from the results obtained and from the analysis of the texts. Both medical and surgical treatment present with similar effectiveness concerning resolution of grades I, II and III of VUR, and the former one is the recommended initial treatment following diagnosis. Endoscopic treatment is exactly as effective as open surgery for grades I, II and III with fewer undesirable effects secondary. There are no differences concerning the efficacy of the different injected substances. Not enough evidences exist for degrees IV and V that may recommend or advise against any of the treatments. In any degree of VUR, open surgical treatment is superior as far as medical treatment is concerned only regarding the number of acute pyelonephritis episodes during followup. This conclusion cannot be applied on endoscopic treatment.

Accuracy of repeated kidney size estimation by ultrasonography and urography in children

The accuracy of repeated sonographic and urographic kidney length measurements in kidney size evaluation was investigated in 80 children 0 to 14 years of age, mean age 4.5 years. At sonography 250 kidney lengths were compared. A difference of 0 to 1.0 cm in repeated length measurement was considered to be good accuracy and 94 per cent of right and 96 per cent of left kidney lengths were found within this interval--a better result than for urography with 76 per cent of repeated right kidney and 79 per cent of kidney lengths within the same interval (94 lengths). Both methods display a variation of kidney length which may lead to under- and overestimation of kidney size and growth. The investigation thus indicates good accuracy for repeated sonographic kidney size assessment which should be repeated often enough to establish a growth chart displaying the trend rather than rely too much on single measurements. Sonography can be highly recommended as a convenient and harmless alternative to urography.

Kidney size in children assessed by ultrasonography and urography

The accuracy of ultrasonographic evaluation of kidney size using the parameter of kidney length was compared with radiographic kidney length assessment by urography. The examination was performed in 102 children 0 to 14 years old in which 427 length comparisons for the right and left kidney were made. Approximately 85 per cent of all differences noted were within a variation interval of 0 to 1.0 cm which was considered to be a good accuracy and consistent with results previously reported. Ultrasonography was therefore regarded as a reliable and suitable alternative to urography in periodic controls of kidney size and growth in children.

Pulmonary edema induced by contrast medium. A comparative investigation in the rat following high intravenous doses of one ionic (diatrizoate) and non-ionic (metrizamide) contrast medium

Monomeric ionic contrast media are known to induce a significant degree of pulmonary edema following intravenous injection of high doses of contrast media in rats. This edema has been shown to be dependent on dose and rate of injection. Metrizamide administered at the same dose causes much less and more transient pulmonary edema than diatrizoate. Although blood osmolalities were significantly and consistently lower following administration of metrizamide compared with diatrizoate, this difference alone does not account for the difference in the degree of pulmonary edema induced by these media.

Pulmonary edema induced by high intravenous doses of diatrizoate in the rat

Using a simple, sensitive model, it has been demonstrated that intravenous administration of high doses of contrast medium can induce pulmonary edema in non-anesthetized rats. The degree of edema formation, which is dependent on the rate of injection as well as dose, is greatest immediately after injection and then decreases slowly. The amount of fluid accumulation in the lungs is related to the chemotoxicity of the medium as other solutions of equivalent hyperosmolality did not induce the same degree of pulmonary edema.

Intravenous urography in neonates and infants. What dose of contrast should be used?

The dose of contrast to be used for IV urography in neonates and infants is discussed. Toxic levels are only just above the currently accepted doses of 2-4.4 ml contrast medium per kg bodyweight. The dangers of expressing the dose of contrast medium as a volume of contrast related to the patient's age are discussed. A case is presented who had a severe reaction following an acceptable dose expressed as volume for age, but probably excessive when expressed as ml per kg bodyweight. It is concluded that for IV urography in neonates and infants the dose of contrast must be related to weight of patient and not its age; no dehydration should be used; and the injection should be slow, taking about three minutes.

Shock and noncardiogenic pulmonary edema following meglumine diatrizoate for intravenous pyelography

In a 25 year old man shock and pulmonary edema developed following the intravenous administration of meglumine diatrizoate for an intravenous pyelogram. A pulmonary-capillary wedge pressure of 3 torr and a high protein content in the pulmonary edema effluent confirmed the diagnosis of noncardiogenic pulmonary edema. We suggest that the basis of the increased capillary permeability in this patient may be related to an immunologic reaction to intravenous pyelogram dye.

Exacerbation of diabetic renal failure following intravenous pyelography

Twenty-two of 29 (76 per cent) diabetic patients with a creatinine level of more than 2 mg/100 ml had exacerbation of renal failure following intravenous pyelography. In nine patients this was irreversible. Particularly at risk seem to be patients with early onset diabetes (less than 40 years), and those patients with severe renal failure (creatine over 5 mg/100 ml). No less that 15 of 16 (93 per cent) such patients had problems after intravenous pyelography; of these, nine (56 per cent) had irreversible deterioration. This report, in context with the increasing number of case reports of similar findin.gs, indicates that intravenous pyelography is dangerous in patients with juvenile onset diabetes who have a creatinine level of more than 5 mg/100 ml.