Downloaded from tech.snmjournals.org by Indonesia: J of Nuclear Medicine Sponsored on November 2, 2020.

For personal
use only.

Iodinated Contrast Media and Their Adverse

Reactions*
Jagdish Singh and Aditya Daftary

Teleradiology Solutions, Bangalore, India

acteristics, including their chemical structure, osmolality,

Cross-use of technology between nuclear medicine and radiol- iodine content, and ionization in solution (2,3).
ogy technologists is expanding. The growth of PET/CT and the The parent molecule from which the contrast agents are
increasing use of intravenous contrast agents during these pro- derived is benzene. This is a toxic water-insoluble liquid.
cedures bring the nuclear medicine technologist into direct con-
The carbon atoms on a benzene ring are numbered clock-
tact with these agents and their associated complications. A
basic understanding of the occurrence, risk factors, clinical fea- wise from 1 to 6. Benzoic acid is produced by introducing
tures, and management of these procedures is of increasing an acid group at position 1 on the benzene ring. This acid
importance to the nuclear medicine technologist. After reading group permits the formation of salts or amides, which
this article, the technologist will be able to list the factors that influence water solubility. 2,4,6-triiodobenzoic acid is ob-
increase the risk of contrast reactions; understand ways to min- tained by introducing iodine atoms at positions 2, 4, and 6
imize the occurrence of contrast reactions; and develop a plan to on the ring. Iodine is the element used in contrast media
identify, treat, and manage the reactions effectively.
as it possesses 3 important properties essential for the
Key Words: iodinated contrast media; contrast reactions
production of contrast media: high-contrast density, firm
J Nucl Med Technol 2008; 36:69–74 binding to the benzene molecule, and low toxicity. Triio-
DOI: 10.2967/jnmt.107.047621 dobenzoic acid is made less toxic and less lipophilic (fat-
soluble) by introducing side chains at positions 3 and 5 (3).

I odinated contrast media are among the most commonly

used injectables in radiology today. Modern iodinated
OSMOLALITY, VISCOSITY, AND IONICITY
Because of their chemical properties, contrast media
contrast agents can be used almost anywhere in the body.
are usually thicker (viscosity) and have greater osmolality
Most often they are used intravenously but can be admin-
(more molecules per kilogram of water) than blood, plasma,
istered intraarterially, intrathecally, and intraabdominally.
or cerebrospinal fluid. Viscosity and osmolality play a part in
They are usually safe, and adverse effects are generally mild
the development of contrast reactions.
and self-limiting. Nonetheless, severe or life-threatening
Ionicity is the characteristic of a molecule to break up
reactions can occur.
into a positively charged cation and a negatively charged
Radiologists and other medical personnel involved with
anion, resulting in more molecules per kilogram of water
the use of iodinated contrast agents must be aware of the
and thus increasing osmolality. Nonionic agents do not have
risk factors for reactions to contrast media. They should be
this property and hence are less osmolar.
aware of and use strategies to minimize adverse events and
Ionic and nonionic contrast media may be monomeric or
be prepared to promptly recognize and manage them (1).
dimeric. Typically, 3 iodine atoms are delivered with each
benzene ring of a contrast medium. If a contrast molecule
THE CHEMISTRY OF IODINATED CONTRAST MEDIA contains only 1 benzene ring, it is called a monomer. To
deliver more iodine with each molecule of contrast, 2
All the currently used contrast media are chemical modi-
benzene rings may be combined to produce a dimer. This
fications of a 2,4,6-triiodinated benzene ring. They are
molecule would deliver 6 iodine atoms with each molecule.
classified on the basis of their physical and chemical char-
In a solution, ionic monomers break up into their anion
and cation components (increasing osmolality), delivering
Received Sep. 27, 2007; revision accepted Dec. 13, 2007.
3 iodine atoms (a 2:3 ratio of osmolar particles to iodine),
For correspondence or reprints contact: Aditya Daftary, Teleradiology whereas ionic dimers would deliver 2 ionic components per
Solutions, Plot 7G, Vishweshwaraiya Industrial Complex, Opposite Graphite
India, ITPL Main Rd., Whitefield, Bangalore, India 560048.
6 iodine atoms (ratio, 1:3). Nonionic monomers do not
E-mail: [email protected] break up in solution; a single molecule delivers 3 iodine
*NOTE: FOR CE CREDIT, YOU CAN ACCESS THIS ACTIVITY THROUGH
THE SNM WEB SITE (http://www.snm.org/ce_online) THROUGH JUNE 2010.
atoms (ratio, 1:3), whereas a single nonionic dimer delivers
COPYRIGHT ª 2008 by the Society of Nuclear Medicine, Inc. 6 iodine atoms (ratio, 1:6). Thus, nonionic dimers are the

IODINATED CONTRAST MEDIA • Singh and Daftary 69

Downloaded from tech.snmjournals.org by Indonesia: J of Nuclear Medicine Sponsored on November 2, 2020. For personal
use only.
TABLE 1
Commonly Used Iodinated Contrast Media

Name Type Iodine content (mg/mL) Osmolality

Ionic
Diatrizoate (Hypaque 50; GE Healthcare) Monomer 300 1,550 (high)
Metrizoate Isopaque (Coronar 370; Nycomed A/S) Monomer 370 2,100 (high)
Ioxaglate (Hexabrix; Mallinckrodt, Inc.) Dimer 320 580 (low)
Nonionic
Iopamidol (Isovue-370; Bracco Diagnostics Inc.) Monomer 370 796 (low)
Iohexol (Omnipaque 350; GE Healthcare) Monomer 350 884 (low)
Iodixanol (Visipaque 320; GE Healthcare) Dimer 320 290 (iso)

most ideal contrast agents as they deliver the most iodine Anaphylactoid/Idiosyncratic Reactions
with the least effect on osmolality. As the name suggests, the exact etiology for these
High-osmolality contrast media (HOCM) have 5–8 times reactions is less well understood, and they tend to mimic
the osmolality of plasma; low-osmolality contrast media an anaphylactic (allergic) reaction. The proposed mecha-
(LOCM) have 2–3 times the osmolality of serum; and nism of these reactions includes enzyme induction, causing
isoosmolar contrast media, which are increasingly used, the release of vasoactive substances such as histamine and
have the same osmolality as blood, plasma, and cerebro- serotonin and the activation of a physiologic cascade and
spinal fluid. eventually the complement system (10).
The incidence of mild and moderate contrast reactions is These are the most frequent type of adverse reactions and
higher for HOCM (6%–8%) than for LOCM (0.2%), but the may have serious, occasionally fatal, complications. These
incidence of severe reactions remains similar. Anaphylac- reactions are more frequent in patients with asthma (5
toid reactions are more common while using HOCM, times), patients with previous reactions (4–6 times), pa-
whereas cardiovascular decompensation is more common tients with cardiovascular and renal disease, and individuals
while using LOCM (4). Commonly used iodinated contrast on b-blockers. Anxiety, apprehension, and fear may play a
media and their characteristics are summarized in Table 1. part in this type of reaction. Such reactions usually begin
within 20 min of injection and are independent of the dose
ADVERSE REACTIONS AND THEIR ETIOLOGY administered. Symptoms associated with anaphylactoid
reactions are classified as mild (skin rash, itching, nasal
Millions of radiology studies are performed with intra-
discharge, nausea, and vomiting), moderate (persistence of
vascular contrast each year. Like all other pharmaceuticals,
mild symptoms, facial or laryngeal edema, bronchospasm,
however, these agents are not completely devoid of risks,
dyspnea, tachycardia, or bradycardia), and severe (life-
and adverse side effects can occur (5–8). Reactions are
threatening arrhythmias, hypotension, overt bronchospasm,
infrequent and range from 5% to 12% for HOCM and from
laryngeal edema, pulmonary edema, seizure, syncope, and
1% to 3% for LOCM (7).
death) (11,12).
A detailed knowledge of the variety of side effects and
their likelihood in relationship to preexisting conditions and
treatment is required to ensure optimal patient care. The
following discussion will assist radiologists, physicians, TABLE 2
and technologists dealing with contrast media in recogniz- Common Factors Predisposing Patient to Contrast
ing and managing contrast-induced reactions. Reactions

Factor Predisposing characteristic

RISK FACTORS FOR CONTRAST REACTIONS
Age Infants and those older than 60 y
Many of the factors that may increase the risk of a con- Sex Females . males
trast reaction are summarized in Table 2. Although it is not Underlying medical Asthma, heart disease, dehydration,
guaranteed that a reaction will develop, it is important to conditions renal disease, diabetes
stay alert for any reactions these patients might exhibit Hematologic Myeloma, sickle cell disease,
conditions polycythemia
(4,5,9).
Medications NSAIDs, IL-2, b-blockers,
biguanides
ETIOLOGY OF CONTRAST REACTIONS Contrast-related .20 mg iodine, faster injection rate,
intraarterial, previous contrast
There are 2 basic types of contrast reactions; the first is reactions
the anaphylactoid or idiosyncratic, and the second is the
nonanaphylactoid. Contrast reactions may occur from ei-
NSAIDs 5 nonsteroidal antiinflammatory drugs; IL-2 5 interleukin-2.
ther one or a combination of both of these effects.

70 JOURNAL OF NUCLEAR MEDICINE TECHNOLOGY • Vol. 36 • No. 2 • June 2008

Downloaded from tech.snmjournals.org by Indonesia: J of Nuclear Medicine Sponsored on November 2, 2020. For personal
use only.
Nonanaphylactoid Reactions TABLE 3
Nonanaphylactoid reactions are also called physioche- Premedication Protocols for Patients with Previous or
motoxic or nonidiosyncratic reactions (13). These reactions Increased Risk for Contrast Reactions
are believed to result from the ability of the contrast media Premedication Protocol
to upset the homeostasis of the body, especially the blood
circulation. These reactions are dependent on the physical Corticosteroids Prednisone: 50 mg orally, 13, 7,
(any of the following) and 1 h before contrast injection
properties of the contrast medium such as ionicity (which
Hydrocortisone: 200 mg intravenously,
causes free ions in the circulation, which in turn may dis- 1 h before contrast injection
rupt electrical charges associated with nervous or cardiac Methylprednisone: 32 mg orally, 12 and
activity) and osmolality (which causes large shifts in fluid 2 h before contrast media injection
volumes). Increasing iodine concentration also increases Antihistamine Diphenhydramine: 50 mg
(optional) intravenously/intramuscularly/
the risk of these reactions. Finally, the volume and route of
orally 1 h before contrast injection
administration of contrast also increase the likelihood of
such reactions (larger volume or intraarterial administration
are more likely to produce a reaction) (1,14). had previous reactions. Although patients who have shell-
The cardiovascular, respiratory, urinary, gastrointestinal, fish allergies are more prone to contrast reactions, this is
and nervous systems are most commonly affected by phys- more likely caused by cross-reactivity between shellfish
iologic changes produced by contrast media. The symptoms and contrast media, rather than by the patient’s inherent
of nonanaphylactoid reactions are warmth, metallic taste, allergic tendency (similar to the reason why patients with
nausea, vomiting, bradycardia, hypotension, vasovagal reac- asthma are more prone to reactions) (16). Various pre-
tions, neuropathy, and delayed reactions (1). medication protocols involving the use of steroids and
antihistaminics are summarized in Table 3 (17,18). Steroid
MANAGEMENT OF CONTRAST REACTIONS premedication is relatively contraindicated in active tuber-
Patient selection and preparation and the actual manage- culosis, diabetes mellitus, peptic ulcer disease, acute lym-
ment of reactions when they occur are 2 essential compo- phoblastic leukemia, and non-Hodgkin’s lymphoma.
nents in the management of contrast reactions.
MANAGING COMMON REACTIONS
Patient Selection, Preparation, and Special Extravasation
Circumstances
Extravasation can occur during hand or power injection
Before administering contrast media, one should assess
in 0.1%–0.9% of cases but is more common in the latter.
the medical history for factors predisposing a patient to
The elderly, infants, children, patients with altered con-
contrast reactions. These factors are summarized in Table 2.
sciousness, and those with underlying vascular disease are
It should be noted that none of the conditions listed in Table
more prone to extravasation. Small extravasations of contrast
2 is an absolute contraindication to administering contrast.
Consultation with the referring physician and radiologist, TABLE 4
on a per-case basis, is necessary to develop guidelines that General Principles for Managing Contrast Reactions
are in the patient’s best interests. Principle Strategy
Once the decision to administer contrast has been made,
secure access should be obtained. The bore of the catheter A Assessment (severity and category of reaction):
blood pressure and pulse monitoring, ECG
should be determined by the rate at which contrast is to be
monitor for evaluation of cardiac rhythm
administered and tested with an appropriate saline bolus Assistance (call for it)
immediately before injection. All air leaks and bubbles Airway, oxygen
should be removed from the injecting system. Access (venous)—secure/improve intravenous
Patient reassurance plays an important role in minimiz- lines
B Breathing (begin cardiopulmonary resuscitation
ing contrast reactions. A step-by-step explanation of the
if necessary, bag-valve mask or mouth mask)
procedure with expected changes (a mild warm flushing at Beware of paradoxical responses (e.g., b-blockers
the site of injection, which spreads over the body and may may prevent tachycardia response)
be particularly intense in the perineum, and metallic taste C Categorize reaction and patient status
that pass away quickly) is reassuring to the patient. Addi- Circulatory assistance, intravenous fluids
Call cardiopulmonary arrest response team if
tionally, in the case of nervous patients, encouraging con-
necessary
tinuous conversation and feedback from the patient during Cardiac output assessment, decreased venous
the scan, if possible, is also helpful. return
D Drugs: dose and route, do not delay
Premedication Do monitor, assess, and reassure patients
A test dose and compulsory premedication are seldom
used in current practice (15). Premedication is considered
ECG 5 electrocardiogram.
in those patients who require intravenous contrast but have

IODINATED CONTRAST MEDIA • Singh and Daftary 71

Downloaded from tech.snmjournals.org by Indonesia: J of Nuclear Medicine Sponsored on November 2, 2020. For personal
use only.
TABLE 5
Management of Common Contrast Reactions

Reaction Etiology Monitor. . . Treatment (28–30)

Anaphylactoid
Urticaria (skin rash) Anaphylactoid Initial size with Usually none; diphenhydramine, 25–50 mg
reaction marking and follow orally/intramuscularly/intravenously;
epinephrine (1:1,000), 0.1–0.3 mL
subcutaneously/intramuscularly
Bronchospasm Anaphylactoid Oxygen saturation, Secure airway; oxygen, 6–10 L/min;
reaction pulse, BP metaproterenol/terbutaline inhaler, 2–3 puffs;
epinephrine (1:1,000), 0.1–0.3 mL
subcutaneously/intramuscularly; epinephrine
(1:10,000), 1 mL intravenously (slowly) if
hypotensive; call the emergency medical team
Facial or laryngeal edema Anaphylactoid Oxygen saturation, Secure airway; oxygen, 6–10 L/min; call the
reaction pulse, BP emergency medical team if severe; epinephrine
(1:1000), 0.1–0.3 mL subcutaneously/
intramuscularly; epinephrine (1:10,000),
1 mL intravenously (slowly) if hypotensive;
call the emergency medical team
Hypotension and Vasodilation Oxygen saturation, Elevate legs 60; oxygen, 6–10 L/min; rapid
tachycardia (fast pulse) pulse, BP intravenous fluids; epinephrine (1:10,000),
1 mL intravenously (slowly); call the emergency
medical team
Hypotension and Vasovagal response Oxygen saturation, Elevate legs 60; oxygen, 6–10 L/min; atropine,
bradycardia (slow pulse) pulse, BP 0.6–1 mg intravenously (slowly); repeat to
total of 2–3 mg (0.04 mg/kg) if needed; call the
emergency medical team
Nonanaphylactoid
Cardiac arrhythmia Ionic abnormalities; Oxygen saturation, Follow ACLS* protocols; call the emergency
chemical variations pulse, BP, ECG medical team
Hypertension Histamine release of Oxygen saturation, Nitroglycerine, 0.4 mg sublingually;
catecholamine pulse, BP, ECG nitroglycerine; 2% ointment; phentolamine,
5 mg intravenously for pheochromocytoma;
call the emergency medical team
Seizures Ionic abnormalities; Oxygen saturation, Secure airway; oxygen, 6–10 L/min; diazepam,
chemical variations pulse, BP, ECG 5 mg intramuscularly/intravenously;
midazolam, 0.5–1 mg intravenously;
phenytoin infusion, 15–18 mg/kg at
50 mg/min; call the emergency medical team
Pulmonary edema Osmolar changes, Oxygen saturation, Secure airway; oxygen, 6–10 L/min; furosemide,
causing large pulse, BP, ECG 20–40 mg intravenously (slowly); morphine,
fluid volume shifts 1–3 mg intravenously; call the emergency
medical team

All medications are to be administered under physician supervision. BP 5 blood pressure; ECG 5 electrocardiogram; ACLS 5 advanced
cardiovascular life support.

media usually produce a local inflammatory response in the Air Embolism

skin, without serious sequela. Larger volumes (50–75 mL) Air embolism is a potentially fatal but rare complication
may produce tissue damage from chemotoxicity or resultant of intravenous contrast injection. Symptoms include dys-
compartment syndrome (19,20). pnea, cough, chest pain, pulmonary edema, hypotension, and
Patients usually present with persistent burning and neurologic deficit. Treatment includes administering 100%
swelling at the injection site. Assessment of the patient’s oxygen and placing the patient in a left lateral decubitus (left
pulse distal to the injection site and documentation of initial side down) position and, if needed, providing hyperbaric
swelling and erythema are essential in early management. oxygen (23–27).
Smaller extravasations may be managed with elevation and
cold compresses. In cases with persistent swelling, pain, Additional Reactions
and discoloration, it is best to consult a surgeon. Compli- Contrast reactions are classified as mild (which are
cations of contrast extravasation tend to be more severe usually self-limiting and resolve quickly with reassurance
with higher-osmolality contrast agents (19,21,22). and without additional intervention), moderate (which take

72 JOURNAL OF NUCLEAR MEDICINE TECHNOLOGY • Vol. 36 • No. 2 • June 2008

Downloaded from tech.snmjournals.org by Indonesia: J of Nuclear Medicine Sponsored on November 2, 2020. For personal
use only.
TABLE 6 rashes have been attributed to contrast media (31). Delayed
Suggested Supplies and Information to Be Made Available reactions are more common in patients with interleukin-2
chemotherapy and in those injected with nonionic dimers
Category Specifics
(31,32). The reactions usually resolve spontaneously and
Posted Name and contact information for are treated with supportive therapy: analgesics to treat head-
information physician on duty, phone number aches, antipyretics for fever, meperidine for rigors, and
of emergency response team
Support Oxygen cylinders, flow valves, tubing,
isotonic fluid for hypotension.
apparatus nasal prongs, oxygen masks (adult
and pediatric sizes), bag-valve mask,
valve masks, endotracheal tubes, Contrast-Induced Nephrotoxicity
laryngoscopes, intravenous fluids Contrast agent–related nephropathy is an elevation of the
(normal saline, Ringer’s lactate) serum creatinine level by more than 0.5 mg/dL or more
Emergency and Defibrillator, ECG, blood pressure/ than 50% of baseline 1–3 d after contrast injection. The
monitoring pulse monitor, pulse oximeter
incidence of contrast agent–related nephropathy is esti-
devices
Medications Epinephrine, 1:10,000, 10-mL preloaded mated to be 2%–7% (33,34). Causes for contrast-induced
syringe; epinephrine, 1:1,000, 1-mL nephrotoxicity include renal hemodynamic changes result-
preloaded syringe; atropine, 1 mg in ing in renal vasoconstriction or direct contrast-induced
10-mL preloaded syringe; b-agonist tubular toxicity. Risk factors of and methods for preventing
inhaler; diphenhydramine for
contrast-induced nephropathy are summarized in Table 7.
intramuscular/intravenous injection;
nitroglycerin, 0.4-mg tabs, sublingually The risks and benefits of nephrotoxicity must be weighed
carefully before administration of intravenous contrast in
these situations. Contrast-induced nephrotoxicity is best
ECG 5 electrocardiogram.
handled by a nephrologist.
Non–insulin-dependent patients with diabetes who are on
longer to resolve and may progress; these usually require biguanide therapy (metformin, glyburide, glucophage, and
medical intervention), and severe (which are life-threatening metaglip) are at particular risk of contrast-induced nephro-
and always require medical intervention). toxicity. Medications must be stopped immediately after
Management of contrast reactions follows the lines of the contrast injection, and they should be restarted by the
usual resuscitation measures used in current medical prac- primary physician 48 h later only after confirmation of
tice. A detailed description of managing contrast reactions normal renal and liver function tests (35).
is beyond the scope of this article, but the basic principles
of their management and some common management strat-
Pregnant and Nursing Patients
egies have been summarized in Tables 4 and 5 (1,5,28–31).
The safety of intravenous iodinated contrast media dur-
Guidelines for suggested medications and information to be
ing pregnancy has not been established. Contrast media can
displayed where contrast would be administered are sum-
cross the placenta, enter fetal circulation, and cause thyroid
marized in Table 6.
disorders (36–39). Intravenous contrast should be used in
SPECIAL SITUATIONS pregnancy only if the possible benefits outweigh the risks.
Delayed Reactions Any elective examination requiring intravenous contrast
Delayed reactions occur between 1 h and 7 d after injection should be deferred until the postpartum period. There is
of contrast in approximately 2% of patients (31). Common now believed to be an extremely low passage of contrast
delayed reactions are flulike symptoms (fever, chills, rashes, into the fetal circulation, of which a very small amount is
pruritus, and nausea). Less-frequent manifestations are par- actually absorbed by the infant; although some mothers
otitis, joint pain, and depression. Many of these are not may cease breast-feeding for 24 h after contrast adminis-
considered to be related to contrast media at all, but the skin tration, the basis for this practice is questioned (39).

TABLE 7
Risk Factors for and Methods to Prevent Contrast-Induced Nephrotoxicity

Risk factor Method

Advanced age, antibiotics (aminoglycosides such as Use the smallest amount of contrast material possible;
gentamycin), cardiovascular disease, chemotherapy, discontinue other nephrotoxic medications before the
collagen vascular diseases, elevated serum creatinine procedure; maintain adequate interval between procedures
levels (variable levels, 1.3–2.0 mg/dL), dehydration, diabetes requiring contrast material; maintain hydration (oral, 500 mL
(insulin-dependent . 2 y; non–insulin-dependent . 5 y), before the procedure and 2,500 mL during the 24 h after the
nonsteroidal antiinflammatory medications, paraproteinemias procedure; intravenous, 0.9% or 0.45% saline, 100 mL/h,
(myeloma), renal disease, kidney transplant beginning 4 h before the procedure and continuing for the 24 h
after the procedure)

IODINATED CONTRAST MEDIA • Singh and Daftary 73

Downloaded from tech.snmjournals.org by Indonesia: J of Nuclear Medicine Sponsored on November 2, 2020. For personal
use only.
CONTRAST REACTIONS IN CHILDREN 17. Lasser EC, Berry CC, Mishkin MM, Williamson B, Zheutlin N, Silverman JM.
Pretreatment with corticosteroids to prevent adverse reactions to nonionic contrast
Pediatric contrast reactions are usually anaphylactoid but media. AJR. 1994;162:523–526.
mild, with reported rates of 0.18% for LOCM and 3% for 18. Seymour R, Halpin SF, Hardman JA. Corticosteroid pretreatment and nonionic
contrast media. AJR. 1995;164:508–509.
HOCM (40,41). Reactions are harder to detect in children 19. Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR. Frequency, man-
than in adults, as children may not be able to communicate agement, and outcome of extravasation of nonionic iodinated contrast medium in
their symptoms. Management of pediatric contrast reactions 69,657 intravenous injections. Radiology. 2007;243:80–87.
20. Federle MP, Chang PJ, Confer S, Ozgun B. Frequency and effects of extrav-
is similar to management in adults, but with age-appropriate asation of ionic and nonionic CT contrast media during rapid bolus injection.
dosing. A special pediatric code chart with appropriate doses Radiology. 1998;206:637–640.
and equipment should be maintained (42,43). 21. Selek H, Ozer H, Aygencel G, Turanli S. Compartment syndrome in the hand due to
extravasation of contrast material. Arch Orthop Trauma Surg. 2007;127:425–427.
22. Schaverien MV, Evison D, McCulley SJ. Management of large volume CT
contrast medium extravasation injury: technical refinement and literature review.
REACTIONS TO ORAL CONTRAST J Plast Reconstr Aesthet Surg. April 23, 2007 [Epub ahead of print].
23. Husain S, Ahmed L, Al-Sawwaf M. Venous air embolism from intravenous CT
Rarely, anaphylactoid reactions have been attributed to contrast administration. J Am Coll Surg. 2006;202:197.
oral contrast media, but these are mostly limited to case 24. Athar MK, Islam T, Grammes J, Athar MN. Near-fatal pulmonary air embolus from
iatrogenic injection of air during contrast administration. QJM. 2005;98:231–232.
reports (44–47). 25. Imai S, Tamada T, Gyoten M, Yamashita T, Kajihara Y. Iatrogenic venous air
embolism caused by CT injector: from a risk management point of view. Radiat
Med. 2004;22:269–271.
26. Wald M, Kirchner L, Lawrenz K, Amann G. Fatal air embolism in an extremely
CONCLUSION low birth weight infant: can it be caused by intravenous injections during
Iodinated contrast media are frequently used and are resuscitation? Intensive Care Med. 2003;29:630–633.
27. Ie SR, Rozans MH, Szerlip HM. Air embolism after intravenous injection of
safe. Reactions, when they occur, are usually mild but may contrast material. South Med J. 1999;92:930–933.
occasionally progress to life-threatening proportions. A 28. American Heart Association (AHA). ACLS: Principles and Practice. Dallas, TX:
thorough understanding of the etiology, predisposing fac- AHA; 2003.
29. American Heart Association (AHA). Advanced Cardiovascular Life Support
tors, symptoms, and management strategies is effective in Provider Manual. Dallas, TX: AHA; 2006.
minimizing the threat posed by these factors. 30. Stiell IG, Spaite DW, Field B, et al. Advanced life support for out-of-hospital
respiratory distress. N Engl J Med. 2007;356:2156–2164.
31. Webb JA, Stacul F, Thomsen HS, et al. Late adverse reactions to intravascular
iodinated contrast media. Eur Radiol. 2003;13:181–184.
REFERENCES
32. Choyke PL, Miller DL, Lotze MT, Whiteis JM, Ebbitt B, Rosenberg SA.
1. American College of Radiology Manual on Contrast Media. 4th ed. Reston, VA: Delayed reactions to contrast media after interleukin-2 immunotherapy. Radi-
American College of Radiology; 1998. ology. 1992;183:111–114.
2. Costa N. Understanding contrast media. J Infus Nurs. 2004;27:302–312. 33. Barrett BJ. Contrast nephrotoxicity. J Am Soc Nephrol. 1994;5:125–137.
3. Bettmann MA, Morris TW. Recent advances in contrast agents. Radiol Clin 34. Barrett BJ, Carlisle EJ. Metaanalysis of the relative nephrotoxicity of high- and
North Am. 1986;24:347–357. low-osmolality iodinated contrast media. Radiology. 1993;188:171–178.
4. Cochran ST, Bomyea K, Sayre JW. Trends in adverse events after IVadministration 35. Sayer JA. Acute renal failure from contrast medium: beware patients taking
of contrast media. AJR. 2001;176:1385–1388. metformin. BMJ. 2006;333:653.
5. Namasivayam S, Kalra MK, Torres WE, Small WC. Adverse reactions to intra- 36. Hill BJ, Saigal G, Patel S, Abdenour GE Jr. Transplacental passage of non-ionic
venous iodinated contrast media: an update. Curr Probl Diagn Radiol. 2006;35: contrast agents resulting in fetal bowel opacification: a mimic of pneumoperi-
164–169. toneum in the newborn. Pediatr Radiol. 2007;37:396–398.
6. Morcos SK, Thomsen HS. Adverse reactions to iodinated contrast media. Eur 37. Vanhaesebrouck P, Verstraete AG, De Praeter C, Smets K, Zecic A, Craen M. Trans-
Radiol. 2001;11:1267–1275. placental passage of a nonionic contrast agent. Eur J Pediatr. 2005;164:408–410.
7. Bush WH, Swanson DP. Acute reactions to intravascular contrast media: types, 38. Moon AJ, Katzberg RW, Sherman MP. Transplacental passage of iohexol. J Pediatr.
risk factors, recognition, and specific treatment. AJR. 1991;157:1153–1161. 2000;136:548–549.
8. Bettmann MA, Holzer JF, Trombly ST. Risk management issues related to the 39. Webb JA, Thomsen HS, Morcos SK. The use of iodinated and gadolinium
use of contrast agents. Radiology. 1990;175:629–631. contrast media during pregnancy and lactation. Eur Radiol. 2005;15:1234–1240.
9. Delaney A, Carter A, Fisher M. The prevention of anaphylactoid reactions to 40. Yunginger JW. Anaphylaxis. Curr Probl Pediatr. 1992;22:130–146.
iodinated radiological contrast media: a systematic review [abstract]. BMC Med 41. Dillman JR, Strouse PJ, Ellis JH, Cohan RH, Jan SC. Incidence and severity of
Imaging. 2006;6:2. acute allergic-like reactions to i.v. nonionic iodinated contrast material in children.
10. Almen T. The etiology of contrast medium reactions. Invest Radiol. 1994; AJR. 2007;188:1643–1647.
29(suppl 1):S37–S45. 42. Lubitz DS, Seidel JS, Chameides L, Luten RC, Zaritsky AL, Campbell FW. A
11. Cochran ST. Anaphylactoid reactions to radiocontrast media. Curr Allergy rapid method for estimating weight and resuscitation drug dosages from length in
Asthma Rep. 2005;5:28–31. the pediatric age group. Ann Emerg Med. 1988;17:576–581.
12. Laroche D, Namour F, Lefrancxois C, et al. Anaphylactoid and anaphylactic 43. Ralston M, Hazinski MF, Zaritsky AL, Schexnayder SM, Kleinman ME. Pediatric
reactions to iodinated contrast material. Allergy. 1999;54(suppl 58):13–16. Advanced Life Support: Provider Manual. Dallas, TX: American Heart Associ-
13. Katzberg R. The contrast media manual. In: McCance KL, Huether SE, eds. ation; 2006.
Pathophysiology: The Biologic Basis for Disease in Adults and Children. St. 44. Seymour CW, Pryor JP, Gupta R, Schwab CW. Anaphylactoid reaction to oral
Louis, MO: Mosby; 1992. contrast for computed tomography. J Trauma. 2004;57:1105–1107.
14. Limbruno U, De Caterina R. Vasomotor effects of iodinated contrast media: just 45. Miller SH. Anaphylactoid reaction after oral administration of diatrizoate
side effects? Curr Vasc Pharmacol. 2003;1:321–328. meglumine and diatrizoate sodium solution. AJR. 1997;168:959–961.
15. Tramer MR, von Elm E, Loubeyre P, Hauser C. Pharmacological prevention of 46. Wolf GL, Mishkin MM, Roux SG, et al. Comparison of the rates of adverse
serious anaphylactic reactions due to iodinated contrast media: systematic review. drug reactions: ionic contrast agents, ionic agents combined with steroids, and
BMJ. 2006;333:675. nonionic agents. Invest Radiol. 1991;26:404–410.
16. Konen E, Konen O, Katz M, Levy Y, Rozenman J, Hertz M. Are referring 47. Armen RN, Cohen SG, Kantor M. Anaphylactoid reaction following the oral
clinicians aware of patients at risk from intravenous injection of iodinated administration of iodide-containing cholecystographic media. J Allergy. 1956;27:
contrast media? Clin Radiol. 2002;57:132–135. 544–547.

74 JOURNAL OF NUCLEAR MEDICINE TECHNOLOGY • Vol. 36 • No. 2 • June 2008

 Downloaded from tech.snmjournals.org by Indonesia: J of Nuclear Medicine Sponsored on November 2, 2020. For personal
use only.

Iodinated Contrast Media and Their Adverse Reactions

Jagdish Singh and Aditya Daftary

J. Nucl. Med. Technol. 2008;36:69-74.

Published online: May 15, 2008.
Doi: 10.2967/jnmt.107.047621

This article and updated information are available at:

http://tech.snmjournals.org/content/36/2/69

Information about reproducing figures, tables, or other portions of this article can be found online at:
http://tech.snmjournals.org/site/misc/permission.xhtml

Information about subscriptions to JNMT can be found at:

http://tech.snmjournals.org/site/subscriptions/online.xhtml

Journal of Nuclear Medicine Technology is published quarterly.

SNMMI | Society of Nuclear Medicine and Molecular Imaging
1850 Samuel Morse Drive, Reston, VA 20190.
(Print ISSN: 0091-4916, Online ISSN: 1535-5675)

© Copyright 2008 SNMMI; all rights reserved.