 Good morning everyone and welcome to today's Ideology Journal Club brought to you by Indian Ideologists. The Ideology Journal Club was started by Indian Ideologists where we have discussions on interesting articles and cases pertaining to the article discussed. We've had several journals up so far on neuroimaging, body imaging, musculoskeletal imaging, breast imaging and so on. The format today is going to be slightly different. We have two special guests with us today, Dr. Nikhil Kamath and Dr. Sarita Nangir, who will be discussing contrast media complications. Before moving on, I would like to thank the entire team at Indian Ideologists, Dr. Shailendra Singh, Dr. Jignesh Thakkar, Dr. Sanjeev Manesar and Dr. Pat Garza for providing us this excellent platform for such educational activities. My colleagues, Dr. Mitusha Verma, Mamta Ma'am and Dr. Amit Pankar, thanks to Bayer Pharmaceuticals for providing us continued support through our various educational activities and especially today we have with us Dr. Sarita Nangir from Bayer Pharmaceuticals. The breast imaging masterclass is postponed to 29th May 2022, so please do join us for that. Also the 21st MRI teaching course is to be held in August on 6th and 7th, 13th and 14th. This is going to be a hybrid course with online as well on site activities. There are interesting offers currently going on, so please do check out an Indian Ideologist website. We will be sharing the links in the chat box as well to submit your papers and posters as well. Also do register for the Sonobas 2023 in Chan on 6th and 8th and the CT bus in October 29th and 30th. Please do make the most of these academic activities. So moving on to our session for today. It's my pleasure to introduce our first speaker, Dr. Sarita Nangir. She's a Regional Medical Advisor Asia Subregion Radiology Bayer Pharmaceuticals based in Singapore. She's worked with G Health Care and Medical Affairs in FISA in India and Abbott India. She's done her bachelor of dental surgery from government dental college in hospital in Mumbai and practices a consultant dental surgeon in India for 7 years. She's done a postgraduate diploma in clinical regulatory battens from India. It's a pleasure to have you with us, Dr. Sarita and over to you. Thank you so much, Dr. Gauri and a good morning everyone who are viewing us today on YouTube and also who are joining us in our live. Thank you so much for this platform and I think a Bayer is always happy to support these kind of educational activities. So I think thanks for the nice introduction, Dr. Gauri and without further ado, I'll move on to my session now. So please let me know if you are able to see my screen once I start sharing it. Can someone confirm if my screen is viewable? Yes. Okay. So hello everyone again and as Dr. Gauri mentioned the format of this radiology club meeting is usually with article review. So though this session is a little different, I'll still be sharing an article review with you all. So the title of this article today, which I'm going to discuss, is based on adverse drug reaction with iodinated contrast media. We know that there are different types of adverse reactions happening with contrast media. It can be mild moderate and severe and based off severity, it can also be in terms of occurrence, it can be kind of immediate or delayed or even very delayed. So here we are talking about a kind of ADR, which is definitely very delayed. And this is regarding the contrast induced acute kidney injury. So just a note here that this particular review article was actually published in 2017 by Falling M. E. Tal in Nature Reviews Nephrology. And of course, since the whole scenario of radiology is evolving, we also have a lot of changes with pertaining to terminologies or even the update of the guidelines. So just to bring it up that the contrast induced acute kidney injury or CIAKI, which we commonly call it as, has now become CAAKI. So it's contrast associated acute kidney injury. But since this particular article is still using CIAKI because it was published before, I'll be using CIAKI and CIAKI interchangeably. So that's one note I had to make before I began this particular talk on CIAKI. So going on to the slides, so now let's see why do we want to talk about this particular adverse drug reaction. We know that the whole scenario of radiology is changing and evolving and the CT examinations are rising dramatically year on year. Along with this increase in CT examinations, we also have increased use of contrast or identity contrast media. So to be able to diagnose with confidence, it's important that we are familiar with the comprehensive data on this particular identity contrast media with respect to image quality, respect to patient comfort and also the safety. Safety can be renal safety, cardiac safety, thyroid safety, general safety and so on. So I think today we have, we are touching two aspects of this particular ADRs here, which is general safety, which Dr. Kamath will be talking after my session. And I will be focusing on renal safety aspect. So now this particular article again from 2017 covers the following points. So first is it tells us about the current knowledge of incidents of CIAKI and also the underlying reasons for discrepancies why the reports of CIAKI occurs differently in different populations or different countries. It also touches on the pathophysiology of CIAKI and also explains why the patients with pre-existing conditions respond differently to the damaging effects of contrast media. And last but not the least, it also discusses the present and future prevention strategies. So there are a few aspects which I have highlighted in this particular study, keeping the time limit in mind. So let's go on to these first slides further. So again, as always, let's start with the definition of CIAKI just as a revision. We know that this is a major health problem. And how do you define CIAKI or CIAKI is when the patient has an increase in serum creatinine by more than 25% or 0.5 milligram per dl. And this happens within three days of intravascular administration of iodinated contrast media or contrast media. And without any alternative etiology, and this particular definition has been taken from ESUR. So now coming on to the incidence of CIAKI, it occurs in up to 30% of the patients who receive iodinated contrast media. And this is considered to be the third most common cause of hospital-acquired CIAKI. The first report of CIAKI dates over to over half a century ago. And this has prompted research and we have seen at least 3,000 publications on CIAKI. Because with 30 million doses of iodinated contrast medium, which are administered annually, the overall harm to patients' health and also the public cost associated with CIAKI are vast. So is there the option of omitting the contrast media? Definitely not. Because we know that omitting the contrast media can lead to suboptimal diagnostic information. Thus, it can compromise the overall therapeutic outcome. So the need to minimize the risk of CIAKI must be balanced against the need to obtain the optimum imaging. And also as caregivers, we can make certain modifications so that we prevent CIAKI happening to our patients post-contrast administration. So now having set the incidence of CIAKI, we know how a major health problem it is. So let's look at the risk factors for CIAKI. So the common risk factors for contrast-induced or contrast-associated acute kidney injury are of two types. One, which is associated with the patient on your box on the right hand side. And the second one, which is associated with the procedure. So the risk factors which are commonly associated with the patient are definitely concomitant, aka of other origins, or the patient has reduced GFR. And of course, he or she had a previous acute kidney injury or chronic kidney disease, or the patient is diabetic and has diabetic nephropathy, or the patient is dehydrated, anemic, has poor hemodynamic status, of course, advancing age more than 70 years. And also the patient is undergoing kind of concurrent nephrotoxic drug treatment, for example, patients with cancers. So those are the common factors which are at high risk for CIAKI associated with the patient. Now, when we look at the procedure, so what are the factors which are associated with the procedure? And they are a risk for their risk factors for CIAKI. So one is definitely we know that large doses of contrast media. So here I would like to highlight that we use Alara principle for radiation, but we can also use that kind of principle as least dose as possible, as is kind of given out in the guidelines. Also, the multiple administrations of contrast media, we need to keep a certain gap if we need to repeat the contrast media or CCT, etc. Also use of contrast media with excessive osmolality or viscosity. And there's a debated risk factor which says that intra-RTL administration is more risky than intravenous administration. So it depends from practice to practice again. So whenever this CIAKI happens, not all cases of CIAKI or AKI are observed after administration of contrast media are not caused by contrast agent alone. There are many risk factors as we just saw and this including renal perfusion, decreased renal perfusion or hypoxemia, the patient hypovolemic, the patient has inflammation or sepsis, etc. They should also be considered. So this means that we have to look at the patient profile before considering the CCT, before choosing the right contrast media for the patient, before choosing the right hydration whenever the profile requires or demands it. And then we have definitely a scope of reducing CAAKI in our patients. So thus, the risk of CAAKI should be calculated in relation to the overall risk of developing AKI in the hospital setting. So now here, I would like to further elaborate on one point which is associated with the procedure or the risk factor which is associated with the procedure, which is use of contrast medium with excessive osmolality or viscosity. So before we talk about this particular point or discuss further, let's go back a bit into our fundamentals and see what is the composition or which is a basic structure of contrast media or iodinated contrast media. So as we already know that iodinated contrast media is basically a tri-iodinated benzene ring with carbon numbers at 2, 4 and 6 and it carries an acidic group. And also in positions 3 and 5, there are other substituents which can be added, which can influence the behavior of contrast media to a large extent, be it reduction of toxicity, reduction of, you know, or influence on lipophilic properties or elimination pathways. So all this currently used iodinated contrast media are chemical modifications of this tri-iodinated benzene ring. So having said that, let's go to the generation of contrast media, iodinated contrast media. So the first generation of iodinated contrast media was ionic monomers. So we know that this particular ionic monomers or group of contrast media, we call as high osmolar contrast media, they, when they actually were injected, they dissociated into kind of positive and negative ions and that actually gave rise to a lot of ADRs. And also the osmolality of this particular group of high osmolar contrast medium was somewhere between 1400 to 2000. Then came the dimer, which is two benzene rings joined together. And here, again, this will actually, the osmolality was 600. But again, because this was ionic, it again caused a lot of adverse drug reaction because they dissociated into positive and negative ions inside the body once injected. Then came the next generation of contrast media, which is non-ionic. And also they were called low osmolar contrast media. So just a point here or highlight that low osmolar contrast media is not lower than the osmolarity of the blood. In fact, it is lower than the osmolality of the previous generations of iodinated contrast media. That's why it's called LOCM or low osmolar contrast media. And here, as you can see, the osmolality had reduced considerably for the molecules, which are mentioned there, iopromide, iohexal, iopamidol. And then recently, we had the invention or the popularity of having IOCMs or isoosmolar contrast media because the osmolality of this particular generation of contrast media was similar to blood, just 290 milliosmoles. But here, having said that, we have a lot of data on low osmolar contrast media. And low osmolar contrast media are the biggest group of contrast media still used across the globe. And since, as I mentioned before, the radiology is evolving, and so are a lot of association guidelines or data which is coming up, and they are influencing the clinical practice or the choice of iodated contrast media for your patients. So let's look at having talked about this particular background in different classes of contrast media. Let's look at what are the important properties. So as I mentioned, it's osmolality and viscosity. And viscosity, as you can see, there are two different tabs for viscosity on your right hand side. One is at 20 degrees, which you call as storage or room temperature. And one section or one column is at 37 degrees, which is at body temperature. So here, as you can see, the viscosity of dimers is always more. And here, as you can see, the viscosity for the low osmolar contrast media or LOCMs, we can see the range from 8.4 to 17.5 at 20 degrees and 4.5 to 8.5 at 37 degrees. So definitely the viscosity decreases when you pre-warm or warm the contrast before you inject into the patient. And look at the last row of contrast media, which is iodic semol or iso osmolar contrast media, where the osmolality is similar to blood, but the viscosity at 20 degrees is 25.4. And at 37 degrees, it's 11.1. So this particular table gives us an idea about how we should be balancing both osmolality and viscosity. And let's see what is the important property which the authors in this particular study are focusing on. So now, before we move on to the properties which the authors of this particular study are focusing on, let's look at the pathophysiological events and preventive strategies in contrast-induced acute kidney injury. So what really happens? So here, as you can see the picture, it looks very busy. So just we will not touch on each and every aspect of it. But the green boxes are basically the contrast agents damage the several components of the kidney, where do they act and how do they act. And the green tabs are basically what are these strategies for prevention of CII, such as fluid expansion or also decreasing oxidative stress, which are based on this particular pathophysiological events. So if we have to go quickly through this particular slide, so here we can see that at the preglomerular vessel level, the of course, the toxic effects of contrast medium is because of, you know, it can cause endothelial damage, oxidative stress or endodeficiency, and which can go cascade into vasoconstriction, decrease in the blood flow and eventually decrease of GFR. And as we go by and go at the tubuli level, here we can see that again, the contrast media has toxic effects on the on this particular tubuli. And this can cause cell damage, apoptosis, etc. And also there is effect of increased urine viscosity, because we know that kidneys filter almost 180 liters of blood every day to produce 1.5 to 2 liters of urine. And they actually kind of reabsorb water throughout throughout the day in that process. So the viscosity of the contrast media, if it's more, actually, we can see we'll see in the next few slides what really happens. But here again, there is a mention of increased viscosity of urine and the effects of the effects of those particular viscosity, where there's increased parankimal pressure, there's increased tubular resistance and pressure, and ultimately, retention of contrast media and decrease of GFR. So here to prevent that, we use kind of strategy like we can give the patient bicarbonate infusion or acetylcysteine or even vitamin C administration based on your hospital protocol. We can also think about fluid expansion, giving the patients saline or oral hydration, though the guidelines mention that oral hydration is the best possible way to prevent CII. Now coming on to the last part of the pathophysiological event, where they can see that in the descending vasarecta, again the toxic effects of contrast medium are inducing the endothelial damage or vasoconstriction and decreased blood flow. Again, there's an effect of increased urine viscosity in this particular part of the kidneys. So which again leads to decreased blood flow, increased resistance and again increased retention of contrast media. And here, the same strategies of bicarbonate, anesthetylsistine or vitamin C administration help to reduce the oxidative stress. So this is something which has been kind of the pathophysiology, we already know about it. But when there were a lot of publications or inquiries about how this particular thing works or how the CII can be prevented, the authors or doctors around the world also started looking at what are the important properties when it comes to choosing a contrast media with respect to preventing CII in the patients. So here as you can see, there was mention of viscosity, increased viscosity of the urine. And we know that if you inject a highly viscous substance or a product, definitely it's difficult for the kidneys to kind of eliminate them very easily from the body. So having spoken about this particular pathophysiology and the preventive strategies, the authors say the following. So this is a very heavy slide, but please stay with me. We will try to make it simple. So as I mentioned that contrast medium is exclusively eliminated by the kidney. After the injection, the contrast media becomes considerably diluted within the bloodstream. So if the viscosity or the osmolarity of contrast media was high, they greatly decrease. It greatly decreases and it becomes diluted within the bloodstream. So all the non-renal organs who are exposed to the low concentrations of contrast medium, there are exceptions. For example, if for patients who are undergoing coronary interventions, they might need to be having locally administered contrast media into coronary arteries and the heart vessels are exposed to high concentrations of contrast media. But otherwise, generally all the other organs are non-renal organs are basically exposed to very low concentrations of contrast media. So what happens after the kind of, they have the whole, after the examination, when they are at the kidneys for excretion, after being filtered at the glomeruli, the contrast medium is not reabsorbed by the tubules because of course it's a waste product. It has to go out of the body. But because of that, the concentration of the contrast agent, it rises on the way through the tubules. So hand in hand, because of the increase in contrast medium concentration, the renal exposure to this particular agent also increases the tubular fluid viscosity. And we know that the concentration and viscosity relationships are exponential. They are not linear. They are very exponential. Thus, the tubular fluid which contains the contrast medium becomes increasingly viscous towards the distal nephron segments. And any increase in this fluid viscosity reduces the flow rate for a given pressure ingredient. Thus the renal tubular congestion can occur depending on the dose and the physical chemical properties of contrast medium and also the hydration status of the patient. So it's important that we need to make sure that the contrast medium is getting cleared off from the kidneys as quickly as possible. So here, this is my third last slide. The authors actually did a small experiment where they actually kind of recorded the data on the viscosity and contrast media concentration in the different layers of the kidney. So as you can see on the left hand side, this particular comparison was between the low osmolar contrast media versus the isosmolar contrast media. The clinically used solutions are kind of highlighted in blue and maybe purple. The whole flow of contrast media may shown through cortex, outer medulla and inner medulla as it passes for excretion. So as you can see the first bar of viscosity where the clinically used solution was X. But as these solutions pass through the cortex, outer medulla and inner medulla, the level of viscosity in the isosmolar contrast medium was markedly more or exceeded the maximum value which a viscometer can measure. So the viscometer can not measure more than 150 millimeters per second. So here the level of viscosity for IOCM was very high and couldn't be measured with the viscometer. Whereas the viscosity level of LOCM or low osmolar contrast medium, which in this case was IOPromide, was only slightly increased as compared to the initial solution. So which clearly shows that viscosity plays an important role basically in kind of preventing a contrast induced acute kidney injury. Now coming on to the right hand side, the most right hand side bar, which talks about the concentration of contrast medium. As a clinically used solution, the concentration was X as you can see which is highlighted in the first red bar on the top. And as we go through the cortex, outer medulla and inner medulla, the 1000 milliosmoles per kg of water, the concentration of low osmolar contrast medium is only slightly elevated. But as of isosmolar contrast medium, it's almost twice as high as the original solution because the contrast media because of the viscosity is getting accumulated. And hence we know that the concentration and viscosity is exponentially related. When the concentration is X, the viscosity can be some X. So this particular slide shows the viscosity levels of contrast media significantly differs in different layers of the kidney. And using a high viscous contrast medium can lead to increased retention and also can also cause problems or can induce CIAKI. So this is the slide which is hello, can I request people who are not talking to please mute yourself? Thank you. So coming on to my second last slide. So concluding this particular study, it's shown always shown that adherence to prevention protocols has likely resulted in a reduction in the incidence of clinically relevant CIAKI. We know that the contemporary contrast media are well tolerated agents and developing contrast media with even better renal safety profiles is possible by considering that fluid viscosity is a primary damaging factor for CIAKI. The incidence of CIAKI will decrease dramatically when volume expansion protocols are implemented worldwide. And also given the protective effect of diluting contrast medium in the tubules, pre-hydration should be considered in all patients. And we also know that oral hydration is highly recommended by all the ACR, ESU and all the guidelines. And the recommendation of NIL per mouth is actually the author here say should be reconsidered. And in ACR 2021 guidelines, it's already there's a whole chapter on fasting, chapter five, which mentions that the patients should not be fasting for CECT examinations or even the GBCA administered examinations. So of course, we have exceptions where they are undergoing the examinations under general anesthesia, but otherwise, they should not be fasting. So this is how the whole study concludes talking about the importance of viscosity in choosing the identity contrast media. Last but not the least, based on this particular study and also a lot of other evidences, we have the guidelines which are recommending recommend something for renal safety, which is the recommendations on the choice of identity contrast media for renal safety. And initially, we thought that for renal safety, it's always ISO or smaller contrast medium. But the all the guidelines recently say that it's not the case. And there is no preference of ISO or smaller contrast medium over low or smaller contrast medium regarding renal safety. So the scientific associations like ACR, National Kidney Foundation, ESUR, Canadian Association of Radiology, British cardiovascular intervention society, and so on and so forth, they have all recommended that the studies have failed to establish a clear advantage of IV isosomalality, iodexanol over the lower or similar contrast medium with regards to PCAKI or CIN. Hence, there are no clinically relevant differences in the risk of CIAKI between these two class of contrast media. So you can either use ISO or smaller or lower smaller for your patient with moderate to severe chronic kidney disease. So that ends my session and I will be happy to take any questions if at all on this particular topic. Thank you very much for the opportunity and I'll stop sharing my screen now. Thank you Dr. Sarita for taking us with an excellent article. I think CAKI is something that each and every radiologist, leader, resident, leader, consultant, fellow, whoever should be completely aware of and thank you so much for doing that for us. If you could share the link to the article in the chat box, Dr. Sarita, I think people could maybe access it later as well. Sure. Sure. I'll do that. I have a few questions right now but in case they do come up, I think you can answer them in the chat box or maybe you can take them in the end up at Dr. Nikhil's lab too. Okay. Thank you so much. Thank you once again. So that was Dr. Sarita for us. Now let's move on to our next session for the day. It's my pleasure to introduce our next speaker, Dr. Nikhil Kamat. Sir is the head of department and senior consultant at Jupiter Hospital. He's had more than 25 years of experience in the field of radiology. He's graduated from St. GS Medical College and KEM Hospital Mumbai. He's done his PG from data Memorial Hospital. He's worked in Bombay Hospital and in Guja for his post-MBE specialized training. He's a D&B guide to students at Jupiter Hospital. He's a visiting fellow. He's been a visiting or he's done a visiting fellowship in radiology at Queen Elizabeth Hospital, Birmingham, a neuro radiology fellowship at Ohio State University in Columbus. Bombay body and musculoskeletal imaging from Massachusetts Denver Hospital, Boston, USA. Sir's topic is contrast media complications, extroversation and fluid overload. Thank you Dr. Nikhil for joining us and over to you. Thank you very much Gauri for introduction. I will start sharing the screen now. Yeah. Are you seeing it now? Yes, sir. Yes. And you can hear me? Yes, sir. Yes. So so after the session of the contrast induced nephropathy, then we will now go on to the other complications that is the extroversation of contrast and the cardiac fluid overload. So these complications are very unusual complications and I'll be talking about 15-20 minutes and these are the practical problems that we face, you know, in the departments, not the theoretical problems. So traditionally the contrast media complications are discussed as ionic versus non-ionic. And as far as the ionic is going, I think the ionic era is going to end because as I was discussing with Sarita, the ionic contrast, the diet rise out, even the bio is stopping the production in February of next year. So it will be more of non-ionic contrast only what we need to discuss. Even the non-ionic contains a lot of iodine. So it will have its own set of complications which will range from mild to severe. So always we discuss the contrast reactions which are mild to severe. The mild reactions everybody knows are the warmth, irritation, itching, allergy, redness. And the severe is anaphylactic reactions and these are very important because they are the very common, you know, each and every patient or some alternate every day, some patient will get these complications and that's why even the staff, the doctors are all aware of these complications. Even the patients are aware of these complications. The second set of complications is a contrast induced nephropathy which Sarita has talked about, but the complications which I am going to talk about in the next 15-20 minutes is the extraversation of contrast and the cardiac failure due to the fluid overload which happens due to contrast which are not much talked about because they are very unusual complications. Fortunately, they are rare and that's why they are not usually discussed and they are not only mentioned very much in the literature as well, but when they occur, like you get these complications say once in a year or maybe once in two or three years, but once it occurs, they are very dreaded and they look horrendous to the patients and that is why it is very important that everybody should be aware that these complications can occur so that just awareness for the patient, for the staff is very essential to prevent these complications and these are important because these complications will also have medical legal issues because the first issue is that whether it is a complications or whether it is a negligence because if there is an extraversation of contrast and then the first thing when there is an extraversation and there is a lot of commotion, the first thing which happens to shout to the sister and the patient feels that there is some negligence, the sister has been very casual in taking the IV line and that is why it has occurred. So whether it is first of all a complication or a negligence, so that issue needs to be solved. The other thing is very important to know is that do this thing feature in your consent forms because when I had these complications and I checked the consent form, actually this extraversation was not mentioned. So all those who are hearing, please go and see whether this extraversation and this cardiac overload are mentioned in the consent. So you are medical legally safe that if they occur then you can show the patients that these were there in the consent and the other thing is the last which is that who bears the cost of treatment in such complication because routinely the minor complications like itching or the redness or the other things which occur you can give AVL, F-coraline and that's a minor or you can give orally to ask the patient and observe. So there's not much of a cost which is involved but if the patient gets extraversation most of the time it's okay that you can just apply eyes, give elevations, give thrombophobe and they are okay but sometimes if there is a compartment syndrome sometimes there may be ischemia, gangrene, there may be requiring a plastic surgery opinion, surgical admission then who will bear the cost of treatment. If the patient feels that this is a kind of negligence he will ask the doctor in the or the center to you know bear the cost of treatment even if the patient has got a fluid overload and patient has to be admitted in ICU for say two days who will bear the cost of treatment. So these are very important practical problems when these complications occur. So just to show you this IV contrast extraversion is a normal hand whereas this is a extraversation which has occurred in the you know in the hand and there's a lot of swelling. Sometimes you can get sinosis you know the hand because of the compartment syndrome is all hand becomes blue and sometimes this is you know it looks very red and hard. So these are like very horrendous when they occur. They are very rare fortunately but when they occur everybody is stunned and you should be you know knowing what to do when such things happen. So to know when these things happen you should be aware not only we but the patient also when before starting when you give the consent always the sister tells that there may be some minor complications or major complications or there may be dead but nobody tells about the extraversation because it is very unusual. Even the staff they should be aware that these complications can occur because if the staff is aware then only then they will take the precautions otherwise what generally happens is that the sister takes a line the automatic injector they inject the contrast when they come out and then there is extraversation the staff you know is not very knowing that such a complication horrendous can occur and it can lead to very lethal or very bad complications but if the staff is being told that such complications can occur you have to be careful then they take the precautions and even we have to tell the sister not make them fearful but tell them that even the vicarious responsibility of the extraversation is with the doctor or the radiologist even the staff who has taken the IV line will be responsible for you not doing the extraversation if you tell the staff they will be more careful while taking an IV line they see they'll get a test dose to see that there is no extraversation and they'll do it properly so just being aware of these complications will prevent and the prevention is the best strategy for this type of complications and we'll also look at what are the causes and the risk factors of these complications and management of the complications if they occur. So contrast media extraversation it refers to the leakage of intravenously administered contrast media from the normal intravascular component into the surrounding tissues during the contrast enhanced CT scanning it can also occur in MR studies but complications are rare given the low volume set are used in MR the maximum type of contrast used is about 5 cc or 10 cc at the most 15 cc but in CT scanning the amount of contrast have in it a contrast about 80 cc 100 cc 120 cc and the complications will depend upon the amount of contrast injected so it is more with the CT injections ok so the extraversation also occurs in fluoroscopy but due to combination of a slow manual injection or small boluses and visualization in the real time of the contrast passing into blood vessel it is rarely an issue. So this is the terminology strictly speaking extraversation should be used for leakage of contrast from blood vessels so if you have injected and this is an x-ray taken after the extraversation if you see that this is a extraversated contrast here and when this happens every I mean it's very difficult and you know it's very hard but then it is the other terminology in a general sense extraversation can be also used for any leakage of contrast if there's an aneurysm there's a leakage of contrast into the peripheral soft tissues or in cases that the if there is a ureteric injury hypoallergenic ureteric injury then there's extraversation of the contrast into the perinephric spaces this is also extraversation but we will not look at this kind of extraversations we are looking only at the extraversations while doing the injections. So to go into the epidemiology of the contrast fortunately the CT contrast media extraversation occurs relatively infrequently to the tune of only 0.5 percent and the range is 0.13 to 0.68 percent of the cases but can have severe side effects associated with skin changes possible skin necrosis so it is an avoidable infrequent but a dreaded complication. What are the risk factors routinely with the automated power injectors which you are using you have to inject large volumes of contrast under pressure in a short time so for particularly for angiographic studies you are using 4 ml per second 5 ml per second so if you are injecting large amounts that will lead to extraversation usually initially when you used to do manual injection extraversation was less likely because there was direct supervision of the contrast medium the sister used to inject by hand if the patient used to get pain she used to stop but now with the automated injection the whole you know before the patient shouts the whole amount of contrast they extracted into the tissues. There are some patient related factors like if there is an elderly patient more chances of extraversation if there is immaciation catechia because this elderly patients have got a lack skin so that no there is a more chance and the patient will have less pain they don't even shout you know if that is getting a pain you just realize that you have injected you come out and when the scan is started you just see that on the screen the scan the post contrast scan is similar to that of a plane scan and you realize that the whole contrast is extraversated so that is you know that is you have to be careful in elderly patients patients who have catechia patients who have marked peripheral edema if they are uncooperative patients for example if the patient is unconscious he will not tell he will not shout and the contrast will get extraversated if there is a pediatric patient they may move well after taking an IV the IV will come out or if there is a patient who is mentally subnormal so that will also move they will the IV would be out and if you are injected it will extraversate so they are there the risk factors to be careful in such patients also the site of venous excess higher percentage of leakage from the venous excess in the back of hand wrist foot and ankle because they are related to the lack skin and a smaller amount of subcutaneous tissue and the fact that the veins are more fragile in this region so if you take an IV line here is a more chance of extraversation the patients undergoing CTR at more risk of developing this extraversation then MR as we already said then the gaze of the intravenous catheter if you are using an 18g or 20g the risk of the contrast is same but if you use a 22g the risk is less but then in 22g you cannot inject under pressure especially for the angiographic studies then as we looked at it high osmolar contrast medium will have more chances of extraversation and as we said in the earlier study if you pre-warm the high osmolar the contrast media to 37 degrees that is a body temperature it will lower the viscosity and it will lower the probability of extraversation so generally our contrast are stored in the contrast to mean ac and usually the temperature is around 20 degrees or 25 degrees and then there is a high viscosity and then that is the more chance of extraversation so if we can pre-warm the contrast it will lower the risk of extraversation so how will the patient clinically present the contrast media extraversation is usually recognized at the time when it happens so usually there are two types of how it happens that patient is partially out the needle is partially out so the patient will get pain his shouts and so if the sister is aware if the technician is aware then they take the time and just stop the injection at the same time but sometimes if there are elderly patients and if they're unconscious patients and the skin is very lax the whole amount of contrast can get extraversed and you will come to know only when you see that on the screen the post contrast study looks plain and you don't see the contrast in the vessels you don't see the contrast in the liver and you see whereas the contrast on it has been injected and you see the whole amount of contrast is extraversed into the subcutaneous regions so that is when how it can present the patients afterwards also will complain of pain at the local site and there is swelling there is pain and tenderness there is itching there is tightness of skin there is redness so if there is a contrast extraversation happens the you know when you see this the we are really bothered you know what will happen what are the complications so at this time we have to maintain our calm we should not start shouting at the sister and you know who is wrong the blame game should start usually starts at the same time if that starts on the patient becomes aware that something is wrong and then then have they will have medical legal issues so the best thing is to remain calm okay and then deal with the situation the complications which occurs are the severe skin ulcerations can occur though it is rare tissue necrosis can occur the compartment syndromes can occur the non-ionic lower smaller contrast medias are known to reduce the risk of soft tissue injury but the potential for soft tissue injury often related to the volume of contrast media that extraversates so if it is more say 100cc 150cc the more the volume the more chances of complications so what is a treatment I mean we should try to avoid the complications but if it occurs what to do there should be a protocol what to do for each radiologist department the first and the foremost as I said there should be awareness between for the radiologist for the junior radiologist for the sisters that can prevent such an occurring but if it occurs discontinue the contrast infusion notify the radiologist immediately if there is a partial extraversation if the contrast has gone into the vessels complete the acquisition of the images of the CT sclerosis because if it is done the damage has been done but at least do the scan then attempted aspiration of the extraversation has been not shown to be effective so you know try to press the skin and try to remove the contrast is not being effective so what to do is you know be calm don't in the front of patients you know try to shout because then they will feel that something is wrong so try to remain calm and if the if the consent has already been taken then that these are the complications which can occur so the patients you can apply the eyes to the affected area elevate the affected extremity to reduce the swelling and then keep the patient under observation for at least two hours the surgical or plastic surgery consultation should be done for all patients whose extraversations involve 100 ml or more contrast media because you know later on there may be a compartment syndrome there may be cyanosis there may be gangrene so you have to avoid make contact with the doctor referring doctor who has referred the patients make you know refer contact him tell him what that complication has occurred it is also suggested to follow up the patient in next few days until the resolution of the local edema this can be accomplished with a phone call to evaluate the regression of the signs and symptoms so call up and ask if there is no more complication most of the times 90% of the times usually we have seen practically that it results you know just by applying eyes give some thrombophobes give some antibiotics or anti-inflammatory agents ask the patient to elate them and usually it recedes but it looks horrible for a couple of weeks so you have to be careful and you know you have to console the patients instruct the patient to notify the staff if there is increased swelling or pain over time blistering, ulceration, induration or other skin changes, altered tissue perfusion or changes in sensations they have to immediately ask us and then in the department make an incidence report don't start a blame game but make an incidence report and instruction to the staff to avoid the repetition so this is few images to show how the the contrast extroversation looks that it complete extroversation in the hand if you take an XT you see that the extroversation is in the subcutaneous regions and these are the things where you know the if a compartment syndrome develops then a plastic syndrome may have to take a nick in order to relieve or decompress the tissue so that you know it doesn't go into the gangrene so very rarely this may be required and you have to be aware of that to take a plastic surgery opinion. So from this contrast extroversation we go to fluid overload the fluid overload is another very unusual type of a complication which we have seen in the last 20 years it's not mentioned too much in the literature what happens is that we notice that the fluid overload causes cardiac failure leading to pulmonary edema so the risk factors are if the patient is old if there is a compromised lvf you know because see routinely for checking out the kidneys we ask for a serum creatinine and ejfr is checked in each and every patient but routinely we don't ask for any lvf in the patients you know generally it is never asked for and if the patient is old if the patient has got a poor left ventricular ejection fraction to the tune of say less than about 25 or something we have noticed that such patients particularly if they are doing a CT scan abdomen and pelvis because for this study we give oral contrast to the tune up about 1 to 1.5 liters and then we inject about 80 to 100 cc of IV contrast so huge amount of fluid has been overloaded and then the patients will go into cardiac failure on table we have seen such five cases in the last five years and they will go into pulmonary edema and they can die in about 5 to 10 minutes after the procedure so you have to look for the lvf the symptoms are the patient is stable before the scan he is very stable he comes he can sometimes even walk up to the table and you know and do the scan immediately after the scan the patient will start feeling breathless on table and further progression with the cuff and secretion seal a watery cuff you know there are so this is the pulmonary edema the patient may have bradycardia and hypotension so this is you know we had five such patients in the we had five such patients in the last 20 years so first time this happened we were not sure what is happening so the first patient which happened at the center not at the hospital so we called in the anesthetist we called in the physicians we thought it was an epileptic reaction they injected all medicines but the patient at pulmonary edema and the patient expired even the second patient was bad we tried to shift him to the hospital and the patient expired and you know but then I realized that in both the patient they were old the left ventricular ejection fraction was very low and then all the both the patients we were doing CT abdomen with you know we were giving oral contrast and lot of IV contrast and this had happened so when the next time in such a case occurred we knew that it was a pulmonary edema both the patients are immediately shifted to the hospital we have a tie up with the you know the either in the hospital we shift them to the casualty or if you are doing it at the center shift them in the closed by hospital and just you have to the treatment is basically it requires immediate admission and you have to do intubation for the airway and they have to give drugs inotropic drugs to maintain the cardiac functions to and then diuretics to flush the excess fluid because they don't have anaphylactic reactions or they don't have any allergic reactions it is just a fluid overload and then should be observation for 28 to 40 years so once we have noticed that this is the kind of complications we could resuscitate to patients and one patient could be even recovered without admission so this complications you should realize that so what happens is if such patients are old patients and if you feel that you know the lbf is going to be poor what we usually do in our center or our setup is we usually do a 2d eco ourselves just because now we are doing cardiac mr we can really see how the you know the ventricles contract on a 2d eco we can just realize if the ventricular function is above 40 or less than 40 if the ventricular function is very poor then what we can do is that we can avoid the oral contrast okay and then even we can limit the IV contrast if you are going about 80 to 100 cc we can limit it to say around 60 to 80 cc that is how we can try to prevent these complications so to conclude the talk the take home points for these two complications are if the extraversation and fluid overload are very rare complications but dreadful and dangerous complications can lead to amputations and death also can lead to medical legal issues so for all this the patient consent if the these complications have to be included in the consent awareness of the staff helps in the prevention and the reduction of damage in management of extraversations if it happens then the conservative management usually you give elevations and cold compress then you communicate to the referring physicians you have to observe and give a surgical reference if there's a large volume and there's tissue necrosis or compartment syndrome and if there's a cardiac fluid overload see for the cardiac function in the elderly so as we said see for the cardiac function try to get lvf or you do yourself and see if there's a the left ventricular ejection fraction is at least more than 40 if it is less than 40 if there's a poor function then avoid the oral contrast limit the IV contrast recognize the symptoms if the patient becomes breathless on table and he has got no allergic reactions and he can give immediate admissions and to maintain a due intubation of the patients and as I said give cardotonic drugs anotropic drugs to maintain the cardiac functions and diuretics to reduce the fluid and the patient can be saved thank you very much thank you dr. nikhil for taking us to that in a very practical manner so thank you so much so awareness and prevention I think we really need to remember that thank you so much for joining us sir so before we end today's session I would like to invite dr. Deepak Patkar sir to please say a few words sir frankly doesn't need an introduction he's the director of medical services head department of imaging at nanavati max super speciality hospital a past president of iris has had more than 33 years experience in the field of radiology with key roles in diagnostics academics and administration he's the past chairman of icri a member of the national steering committee for mr i headed by iit he's received the best radiology teacher award and several other awards for his contribution to radiology has delivered more than 1000 lectures in orientations at several national international conferences as more than 170 national and more than 18 international index publications so the postgraduate teacher for bnb for the last 20 years he's a passionate teacher several students have learned under his guidance and are now successfully placed all over the world it's a pleasure to have you with us sir and over to you sir thank you gauri and thank you nikhil and dr. sarita for the presentation today i heard the last half of nikhil's presentation it's very important for all of us to understand what we do every day and uh the problem that are associated with all of us get kind of careless when we inject contrast whether in the city or mr we read about statistics and we think the statistics does not hold true for us the law of averages will always catch up and we should be always prepared when we give contrast whether it is young person debilitated person renal compromised person or even otherwise in fact when the person is renal compromised at most care forgetting that even a normal person like you and me can get into trouble while taking contrast uh it of course is an immense pleasure to be addressing you on this platform reader in general club we have been doing this for last a year or so and gauri mithusha and dr. mithunkar have been kind of thought-bearer of this this idea was from indian radiologist idea again is to keep the young radiologist students updated with what is happening uh on the latest forefront in the radiology so pick up good articles pick up good topics and talk about that whether they are regular or not so common it's also a good idea to keep in touch with the young readers who are into early practice and they need to know what's happening around them uh a special mention about what is coming up uh in next few months on indian news platform we have two masterclasses coming up one on breast and rather two on msk one on small joints and one on large joints m rg course is coming up in mid august uh sonobas city bus will happen by year end and links and ways to register for all these activities are available on indian readers platform website as well as other social platforms so thank you again and thank you doctor sarita for doing what you did today thank you gauri for conducting the session thank you so much for joining us sir dr. nikhil sir there are no questions right now but if y'all could leave your email id maybe in the chat box you know people have any queries or questions they can always reach out sure nick a lot of people will ask questions during the day because uh a few students would see it on youtube yeah and i think by end of the day you'll have about 500 600 people going through this that has been the that has been the past history okay so no questions during the day and gauri will get in touch or a little bit in touch in case uh that question will remain thank you nikhil sure yeah thank you thank you sir so thank you once again doctor sarita dr. nikhil for joining us sir and it's been an enlightening session thank you once again so that brings us to the end of today's sessions thank you everyone who's been tuned in all these sessions are available on youtube as well so please do spread the word ask your friends to join in and tune in later on just a reminder once again several academic events coming up just like so just mentioned the 21st MRI teaching course so moobah ct bus the breast imaging master class as well as the msk master class so all the details are available in the um in the neurologist website i've also shared the links in the chat box so you can access them there there are several offers going on right now so you can make the most of that as well so before we wrap up a good thanks to the entire team of community colleges dr. shelly and the sink sir dr. james chakran mahi sir partner sir and of course my dean dr. mithusham and the ma'am dr. amit punkar dr. nikhil dr. sarita mr. kedar from bayers who's also joined us and thanks to everyone who's joined us today so we will see you all next month again with another journal another interesting idea do send us your suggestions it always open to new ideas so please do can share them on email you can what's happened to me dr. mithusham dr. amit so thank you dr. amit we can have the