I MMEDI ATE ADVERSE REACTI ONS TO I NTRAVENOUS I ODI NATED
CONTRAST MEDI A I N COMPUTED TOMOGRAPHY
1Beat r iz Cav alcant i Juchem2 Clar ice Mar ia Dall’Agnol3
Juchem BC, Dall’Agnol CM. I m m ediat e adv er se r eact ions t o int rav enous iodinat ed cont rast m edia in com put ed t om ography. Rev Lat in o- am En fer m agem 2 0 0 7 j an eir o- fev er eir o; 1 5 ( 1 ) : 7 8 - 8 3 .
This ex plor at or y - descr ipt iv e, non- ex per im ent al quant it at iv e r esear ch aim ed t o lear n about im m ediat e ad v er se r eact ion s t o in t r av en ou s iod in at ed con t r ast m ed ia in h osp it alized p at ien t s su b m it t ed t o com p u t ed t om ography at a t eaching hospit al in t he Sout h of Brazil. During t he st udy period, all adverse react ions showed m ild int ensit y , at a fr equency of 12. 5% w it h ionic iodinat ed cont r ast m edia, and 1% w it h non- ionic cont r ast agent . The ext ravasat ion of cont rast occurred in 2.2% of t he inj ect ions in a peripheral vein wit hout com plicat ions in any of t he cases. The result s are wit hin t he lim it s cit ed in int ernat ional lit erat ure and suggest t hat t om ography ser vice pr ofessionals should know t heir ow n r at es of adver se r eact ions t o iodinat ed cont r ast agent , as w ell as t he condit ions in which t hey occur, in order t o obt ain evidence t o evaluat e t he respect ive care delivery processes.
DESCRI PTORS: cont r ast m edia/ adv er se effect s; ex t r av asat ion of diagnost ic and t her apeut ic m at er ials/ nur sing; t om ogr aphy spir al com put ed; dr ug m onit or ing
REACCI ONES ADVERSAS I NMEDI ATAS AL CONTRASTE YODADO
I NTRAVENOSO EN TOMOGRAFÍ A COMPUTARI ZADA
I n v est igación cu an t it at iv a del t ipo ex plor at or io- descr ipt iv o, de car áct er n o ex per im en t al. El obj et iv o consist ía en conocer las reacciones adversas inm ediat as al cont rast e yodado int ravenoso en pacient es int ernados, som et idos a t om ografía com put arizada en un hospit al escuela del sur de Brasil. Durant e el período del est udio, t odas las reacciones adversas t uvieron int ensidad leve y una frecuencia del 12,5% con la ut ilización del cont rast e yodado iónico, y 1% con cont rast e no iónico. La ext ravasación del cont rast e ocurrió en un 2,2% de las inyecciones en v en a per ifér ica, n o ocasion an do com plicacion es en n in gu n o de los casos. Los ín dices ev iden ciados en el pr esen t e est u dio se m an t u v ier on den t r o de los lím it es qu e con st an en la r ev isión de lit er at u r a y , en t r e las r ecom en d acion es, se su g ier e q u e los ser v icios d e t om og r af ía con ozcan los p r op ios ín d ices d e r eaccion es adv er sas al cont r ast e y odado y las condiciones en que ocur r en, con la finalidad de obt ener ev idencias par a ev alu ación de los r espect iv os pr ocesos asist en ciales.
DESCRI PTORES: m edios de cont rast e/ efect os adversos; ext ravasación de m at eriales t erapéut icos y diagnóst icos/ en fer m er ía; t om ogr afía com pu t ar izada espir al; m on it or eo de dr ogas
REAÇÕES ADVERSAS I MEDI ATAS AO CONTRASTE I ODADO
I NTRAVENOSO EM TOMOGRAFI A COMPUTADORI ZADA
Pesquisa quant it at iva, explorat ório- descrit iva, de carát er não experim ent al, com o obj et ivo de conhecer as r eações adv er sas im ediat as ao con t r ast e iodado in t r av en oso em pacien t es h ospit alizados, su bm et idos a t om ogr af ia com pu t ador izada n u m h ospit al- escola n o Su l do Br asil. Du r an t e o per íodo de est u do, t odas as r eações adv er sas m an if est ar am - se n a in t en sidade lev e, com f r eqü ên cia de 1 2 , 5 % com o u so de con t r ast e iod ad o iôn ico e 1 % com con t r ast e n ão iôn ico. Ex t r av asam en t o d o m eio r ad iop aco ocor r eu em 2 , 2 % d as in j eções em v eia per ifér ica, n ão h av en do com plicações em n en h u m dos casos. Os r esu lt ados en con t r am - se dent r o dos lim it es cit ados na lit er at ur a int er nacional e suger e- se que os ser v iços de t om ogr afia conheçam as pr ópr ias t ax as de r eações adv er sas ao cont r ast e iodado e as condições em que elas ocor r em , a fim de obt er ev idên cias par a a av aliação dos r espect iv os pr ocessos assist en ciais.
DESCRI TORES: m eios de cont r ast e/ efeit os adver sos; ext r avasam ent o de m at er iais t er apêut icos e diagnóst icos; en f er m agem ; t om ogr af ia com pu t ador izada espir al; m on it or am en t o de m edicam en t os
Disponible en castellano/ Disponível em língua portuguesa SciELO Brasil w w w .scielo.br/ rlae
1
I NTRODUCTI ON
A
d v e r se r e a ct i o n s t o i o d i n a t e d co n t r a st m edium happen relat ively frequent ly in daily w ork atim aging unit s, and t heir occur r ence can r ange fr om
ligh t f or m s t o lif e- t h r eat en in g ev en t s. I n t er n at ion al
st udies indicat e t hat t hese ev ent s occur in bet w een
0 . 2 and 1 2 . 7 % of cont r ast inj ect ions, depending on
t h e t y p e a n d c h a r a c t e r i s t i c s o f t h e r a d i o p a q u e
su b st an ce t h at is u sed( 1 - 2 ). How ev er, t h er e ar e n o
n at ion al p u b licat ion s ab ou t t h e f r eq u en cy of t h ese
r eact ion s in Br azilian r adiology ser v ices. Th u s, t h is
r esear ch aim ed t o find out about im m ediat e adv er se
react ions present ed by hospit alized pat ient s subm it t ed
t o co m p u t e d t o m o g r a p h y ( CT) w i t h i n t r a v e n o u s
iodinat ed cont rast , at a t eaching hospit al in t he Sout h
of Brazil. A furt her goal was t o ident ify t he frequency
of t hese ev ent s and est ablish a par allel w it h r esult s
f r om in t er n at ion al r ef er en ces. Th is k n ow led g e can
support care and m anagem ent decisions, cont ribut ing
t o m or e q u alif ied an d sp ecialized car e d eliv er y t o
client s subm it t ed t o t om ogr aphies.
LI TERATURE REVI EW
I odinat ed cont rast is a radiopaque subst ance
used in radiology ex am s like com put ed t om ography,
which is widely used for diagnost ic purposes. Alt hough
it im pr ov es t h e v isu alizat ion of an at om ic st r u ct u r es
d u r i n g t h e e x a m , t h i s s u b s t a n c e c a n p r o v o k e
unwant ed adverse effect s, m ainly due t o t he cont rast ’s
high osm olalit y in r elat ion t o blood( 3). I onic iodinat ed
con t r ast is d issociat ed in ion s w h en solv ed an d it s
osm olalit y is higher t han t hat of so- called non- ionic
com pounds, w hich do not dissociat e int o elect r ically
-loaded par t icles. Ther efor e, t he non- ionic m edium is
safer and has a bet t er t oler abilit y, but it s high cost
im pedes it s indiscr im inat e use( 4- 5).
Adv er se r eact ions ( AR) or unw ant ed effect s
r esu lt in g fr om iodin at ed con t r ast adm in ist r at ion ar e
g e n e r a l l y c l a s s i f i e d , i n t e r m s o f e t i o l o g y, i n
a n a p h y l a c t o i d a n d c h e m o t o x i c r e a c t i o n s .
Anaphylact oid or idiosyncrat ic react ions do not depend
on t he adm inist er ed cont r ast dose and ar e sim ilar t o
aller gic r eact ions, t ak ing t he for m of ur t icar ia, nasal
c o l d , h y p o t e n s i o n a c c o m p a n i e d b y t a c h y c a r d i a ,
b r on ch i al sp asm an d l ar y n g eal ed em a, as w el l as
m or e in t en se m an if est at ion s lik e sh ock an d sev er e
r espir at or y f ailu r e. Ch em ot ox ic or n on - idiosy n cr at ic
r ea ct i o n s a r e d o se- d ep en d en t a n d r el a t ed t o t h e
con t r ast ’s ph y sical- ch em ical ch ar act er ist ics, su ch as
osm olalit y and ionicit y. Their signs and sym pt om s can
include feelings of heat , nausea and v om it ing, hear t
a r r h y t h m i a , h y p e r t e n s i o n , r e n a l f a i l u r e a n d
con v u lsion s, am on g ot h er s( 4 ). As t o sev er it y lev el,
r e a ct i o n s a r e cl a ssi f i e d a s l i g h t , w h e n t h e y p a ss
spont aneously and no t her apy is needed; m oder at e,
w h e n t h e r e a c t i o n r e c e d e s t h r o u g h m e d i c a t i o n
i n t er v en t i on , w i t h ou t n eed i n g h osp i t al i zat i on ; an d
s e v e r e , w h e n l i f e - s u p p o r t m e a s u r e s a n d
hospit alizat ion are required( 2,4). Adverse react ions are
called acut e when t hey occur wit hin 30 m inut es aft er
cont rast adm inist rat ion and lat e when t hey occur aft er
30 m inut es and up t o seven days lat er( 5). Risk fact ors
associat ed w it h t he occur r ence of adv er se r eact ions
t o i o d i n a t e d co n t r a st i n cl u d e p r e v i o u s h i st o r y o f
adv er se r eact ions t o r adiopaque m edium , hist or y of
ast hm a or allergies, heart arrhyt hm ias, ischem ic heart
disease, gener al w eak ness, im pair ed com m unicat ion,
anxiet y, kidney failure, ext rem e age and concom it ant
use of som e drugs, such as bet a blockers, m et form in
and nephrot oxic agent s( 4- 6). The frequency of adverse
ev en t s a sso ci a t ed w i t h i o d i n a t ed co n t r a st r a n g es
bet w een 2. 2 and 12.7% w hen ionic m edium is used
and bet w een 0. 2 and 3. 1% w hen non- ionic cont r ast
is used( 1- 2,7).
I o d i n a t e d c o n t r a s t e x t r a v a s a t i o n i s
co n si d e r e d a l o ca l a d v e r se e f f e ct o f i n t r a v e n o u s
r a d i o p a q u e s u b s t a n c e a d m i n i s t r a t i o n . M o s t
ext r avasat ions involve sm all volum es of less t han 10
m l, ev olv in g w it h ou t com p licat ion s; h ow ev er, lar g e
v olum es of 5 0 m l or m or e can dam age neighbor ing
t issues of t he punct ure sit e and, rarely, com part m ent al
sy n dr om e( 6 ). Accor ding t o int er nat ional lit er at ur e( 2 , 8
-10)
, t he frequency of radiopaque m edium ext ravasat ion
v ar ies bet w een 0 . 3 % an d 3 . 6 % . Som e r isk f act or s
f o r t h e o ccu r r e n ce o f co n t r a st e x t r a v a sa t i o n a r e
f r agilit y of t h e v en ou s n et w or k , v en ipu n ct u r es w it h
m et allic needles in com parison w it h plast ic cat het ers,
p r e v i o u sl y ca t h e t e r i ze d v e i n s, m u l t i p l e p u n ct u r e
at t em p t s, i m p ai r ed co m m u n i cat i o n , ex t r em e ag e,
e a r l i e r o r cu r r e n t ch e m o t h e r a p y o r r a d i o t h e r a p y
t r eat m ent( 6,11).
Th e n u r s i n g t e a m a c t i v e i n c o m p u t e d
t om ogr aph y ser v ices play s an im por t an t r ole in t h e
prevent ion, det ect ion and t reat m ent of adverse effect s
cau sed b y iod in at ed con t r ast u se. At t h e r esear ch
h o sp i t a l , n u r si n g e x a m i n e s t h e p r e se n ce o f r i sk
f or v en ou s access an d in j ect s t h e con t r ast ag en t .
Mo r e o v e r, n u r si n g p r o f e ssi o n a l s i d e n t i f y si g n s o f
sy st em ic or local ad v er se r eact ion s an d im p lem en t
t h e t r e a t m e n t n e e d e d f o r e a ch ca se . He n ce , t h e
m o n i t o r i n g o f a d v e r s e e v e n t s d e r i v i n g f r o m
t om ographies is a t ool t o assess care delivery at t his
ser v ice and an im por t ant car e qualit y indicat or.
METHOD
A q u an t it at iv e, ex p lor at or y - d escr ip t iv e an d
pr ospect iv e st u dy w as car r ied ou t at t h e Radiology
Service of t he Port o Alegre Hospit al de Clínicas ( HCPA) .
Th is gen er al pu blic h ospit al belon gs t o t h e h ospit al
n e t w o r k o f t h e Br a z i l i a n H e a l t h Mi n i s t r y a n d i s
academ ically affiliat ed wit h Rio Grande do Sul Federal
Universit y ( UFRGS) . The HCPA has approxim at ely 830
beds and, every m ont h, t he Tom ography Unit perform s
about 900 t om ographic exam s. This non- experim ent al
r esear ch w as f av or ab ly assessed b y t h e Resear ch
Gr ou p an d t h e Gr adu at e Pr ogr am at t h e in st it u t ion
t hr ough am endm ent 1 of Pr oj ect GPPG 02- 342. Dat a
were collect ed t hrough a regist ry fram ework, filled out
m an u ally b y t h e n u r sin g t eam d u r in g t h e ser v ice’s
funct ioning hours ( 24/ 24) , including all hospit al pat ient s
who underwent cont rast ed CT bet ween Oct ober 1st and
Decem ber 10t h 2004. Aft er t he ex am , pat ient s w er e
assessed f or t h e occu r r en ce of im m ed iat e ad v er se
react ions deriving from t he use of int ravenous iodinat ed
cont r ast dur ing t he 30 m inut es aft er t he r adiopaque
m ed iu m w as ad m in ist er ed . At t h e en d of t h e d at a
co l l e ct i o n p e r i o d , a sa m p l e o f 3 5 1 su b j e ct s w a s
obt ained, 161 of whom received ionic iodinat ed cont rast
( m eglu m in e diat r izoat e) an d 1 9 0 r eceiv ed n on - ion ic
iodinat ed cont rast ( iov er sol) . To st udy ex t ravasat ion,
o n l y su b j ect s w h o r ecei v ed t h e co n t r act i n j ect i o n
t h r o u g h p er i p h er a l v en o u s a ccess w er e i n cl u d ed ,
t ot aling 317 pat ient s.
Dat a w er e t r eat ed t h r ou g h d escr ip t iv e an d
analyt ic st at ist ics, using SPSS v. 12.0, EPI I NFO v. 6
and PEPI v. 3. Chi- square and Fisher ’s exact t est were
u se d t o ch e ck f o r p o ssi b l e a sso ci a t i o n s b e t w e e n
v ar iables, con sider in g p< 0 . 0 5 as sign if ican t , w it h a
9 5 % confidence int er v al ( CI ) .
Nex t , in t he r esult s sect ion, findings r elat ed
t o ex t r a v a sa t i o n o f t h e r a d i o p a q u e m ed i u m w er e
descr ibed separat ely, as t his is a local adver se effect
f o r w h i ch d i f f e r e n t sa m p l e su b j e ct i n cl u si o n a n d
ex clusion cr it er ia w er e adopt ed.
I MMEDI ATE ADVERSE REACTI ONS
I n t h e gr ou p of 1 6 0 pat ien t s w h o r eceiv ed
i o n i c i o d i n a t e d c o n t r a s t , w e f o u n d 2 0 c a s e s o f i m m ed i a t e a d v er se r ea ct i o n s, co r r esp o n d i n g t o a
fr equency of 12.5% ( CI95%: 8.0% ; 18.3% ) . Eight y - fiv e p e r ce n t o f r e a ct i o n s w e r e a n a p h y l a ct o i d , m a i n l y
charact erized by prurit ic papules and, less frequent ly, b y f a c e h y p e r e m i a a n d s n e e z i n g . Ch e m o t o x i c
r eact ions only t ook t he for m of v om it ing.
Am on g t h e 1 9 1 p at ien t s w h o r eceiv ed t h e
n o n - i o n i c m e d i u m , o n l y t w o ca se s p r e se n t e d a n
i m m e d i a t e a d v e r s e r e a c t i o n s , e x c l u s i v e l y charact erized by vom it ing, corresponding t o a react ion
frequency of 1.0% ( CI95%: 0.2% ; 3.4% ) . This rat e was significant ly low er t han w hen ionic cont r ast agent is
used ( p= 0.000) , support ing t he assert ion t hat t he non-ionic m edium , wit h lower osm olalit y, drast ically reduces
t he risk of adverse react ions( 4). I nt ensit y of all event s w a s l i g h t , w i t h s i g n s a n d s y m p t o m s r e c e d i n g
spon t an eou sly, an d 5 4 . 6 % of ev en t s st ar t ed w it h in t he fir st t en m inut es aft er cont r ast adm inist r at ion.
I n Ta b l e 1 , r a t es f o u n d i n t h i s st u d y a r e
com par ed w it h in t er n at ion al r efer en ces, sh ow in g n o sig n if ican t d if f er en ce b et w een t h ese r esu lt s an d a
Japanese research( 1). That study included feeling hot as an adverse reaction, with a frequency of 2.29% for ionic
m edium and 0.92% for non- ionic m edium , while t hat sy m pt om s w as not consider ed her e. Ot her aut hor s( 7)
ignore not only feeling hot , but also t he occurrence of vom it ing. Therefore, when drawing a parallel wit h t he
r esu lt s of t h at r ef er en ce sou r ce, m an if est at ion s of
v o m i t i n g w e r e e x cl u d e d . Re su l t d i f f e r e n ce s w e r e sig n if ican t f or ion ic iod in at ed con t r ast u sag e on ly ;
however, it should be highlighted that those researchers do not distinguish between light and m oderate reactions,
g r o u p i n g t h em i n o n e si n g l e cat eg o r y o f ad v er se reactions. This m eans that, although this study found a
higher rat e of adverse event s when ionic cont rast was u sed , t h ese ev en t s w er e less sev er e, as t h ey on ly
referred t o light react ions.
Tab l e 1 - Co m p ar i so n b et w een AR r at es f o u n d i n
int er nat ional publicat ions and in t his st udy
f o r a e y , s r o h t u A
n o it a c il b u
p ApRurbatilceainitotnhe ARratsetuindcyurrent FisheTe'rssEtxact
, a m a y a t a K
, a k u z o K ,i h c u g a m a Y
, z e e S , a m i h s a k a T
0 9 9 1 , a r u u s t a
M (1)
% 6 6 . 2 1 = * M C I c i n o
I IonicICM=12.5% p=0.951
= M C I c i n o i-n o N
% 3 1 .
3 Noni-onicICM=1.0% p=0.098
, z e h c n á S , a í d n A , s ll a V
3 0 0 2 , o n e r o
M (7)
% 2 . 2 = M C I c i n o
I IonicICM=10.6% p<0.001
% 0 , 0 = o c i n i o ã n I C
M p<0,001 p=0,627
As t o t h e co n t r a st v o l u m e u se d f o r e a ch
exam , it was observed t hat t he radiopaque subst ance dose, expressed in m l/ kg, is not a det erm inant fact or
f or t h e occu r r en ce of adv er se r eact ion s in gen er al, neit her for ionic nor for non- ionic iodinat ed cont r ast .
S o m e s t u d i e s( 1 - 2 , 8 ) h a v e a d d r e s s e d t h e i n f l u e n ce o f t h e i n j e ct i o n t e ch n i q u e o r co n t r a st
ad m in ist r at ion sp eed on t h e occu r r en ce of ad v er se ev en t s, bu t t h ese in t er n at ion al r esear ch r esu lt s ar e
cont r ov er sial. I n t his st udy, w e found t hat aut om at ic c o n t r a s t i n j e c t i o n s i g n i f i c a n t l y i n c r e a s e d t h e
occurrence of adverse react ions, but only in t he ionic
group: m anual inj ect ion provoked AR in 3.6% of cases, while inj ect ions t hrough an inj ect ion bom b result ed in
17. 1% ( p= 0. 013) .
When considering t he influence of som e client
-r e l a t e d v a -r i a b l e s , l i t e -r a t u -r e( 1 ) r e p o r t s h i g h e r pr ev alence r at es for all adv er se r eact ions w it h bot h
cont rast t ypes in t he age range from 20 t o 29 years, w it h a sig n if ican t d ecr ease in f r eq u en cies f or each
y ear added t o t he pat ient ’s age. Hence, t he y ounger t he pat ient , t he higher t he pr obabilit y of dev eloping
an im m ediat e or lat e adv er se r eact ion t o iodin at ed
con t r ast( 1 2 ). I n f act , in t h is st u dy, t h e f r equ en cy of r eact ion s t o t h e ion ic m ed iu m d ecr eased f r om t h e
age of 30 onwards. However, no st at ist ically significant differ ence occur r ed for adv er se r eact ions in gener al
in differ ent age r anges ( p= 0.684) .
Anot her im por t ant char act er ist ic of client s in
t h i s st u d y i s t h a t 7 6 . 6 % o f t h e sa m p l e su b j e ct s p r esen t ed on e or m or e r isk f act or s f or d ev elop in g
adverse react ions t o t he radiopaque subst ance, which
w ere m ore frequent in people over 70 ( 25.6% ) , w it h a hear t disease ( 1 6 . 0 % ) , diabet es m ellit us ( 1 1 . 1 % )
an d v ar iou s aller gies ( 1 0 . 0 % ) . Differ en t st u dies( 1 , 1 2 ) indicat e t hat t he r at e of adv er se r eact ions incr eases
about t hr ee t o fiv e t im es in t he pr esence of fact or s like a hist ory of previous react ion t o iodinat ed cont rast ,
v ar iou s aller g ies an d ast h m a. I n t h is r esear ch , n o si g n i f i ca n t d i f f er en ce w a s f o u n d i n a n a p h y l a ct o i d
adverse event rat es wit h ionic iodinat ed cont rast usage b e t w e e n t h e g r o u p w i t h a n d t h e g r o u p s w i t h o u t
a l l e r g i c a n t e c e d e n t s : 1 5 . 4 % v e r s u s 1 0 . 2 % ,
r espect iv ely, w it h p= 0. 911.
RADI OPAQUE MEDI UM EXTRAVASATI ON
Contrast extravasation occurred in 7 of the 317
pat ient s who received t he inj ect ion t hrough peripheral v enous access, cor r esponding t o a fr equency r at e of
2.2% ( CI95%: 1.0% ; 4.1% ) , without any relation with the
t y p e o f co n t r a st t h a t w a s u se d . Th e v o l u m e o f ext ravasat ed cont rast ranged bet ween 1 and 10 m l in
85.7% of cases, and only one case ( 14.3% ) with a volum e of 1 5 m l. All cases ev olv ed f av or ab ly, w it h ou t any
com plicat ion deriving from t hese event s.
On e fact or t h at w as clear ly associat ed w it h
t he occurrence of ext ravasat ion was t he m at erial used f o r t h e p e r i p h e r a l v e n i p u n ct u r e . Usu a l l y, v e n o u s
access i s ar r an g ed i m m ed i at el y b ef o r e t h e ex am , using a 21- caliber m et allic needle for m anual inj ect ion
an d a 2 2 - caliber plast ic cat h et er for cases in w h ich
t he radiopaque m edium will be inj ect ed aut om at ically t h r o u g h a n i n j e ct i o n b o m b . Pr e v i o u sl y i n st a l l e d
cat het ers are only used if t hey are in good condit ions, t hat is, if est ablished less t han 24 t o 48 hour s ago,
offering a good flow of 0.9% saline solut ion, inj ect ed in bolus t o t est t he access; an adequat e blood reflow;
and no sign of phlebit is, such as pain, edem a or local h y p er em ia. I n or d er t o av oid p ossib le v er if icat ion
biases, ext ravasat ion frequency according t o t he t ype o f v en o u s a ccess w a s ca l cu l a t ed w i t h a co n st a n t
m an u al con t r ast in j ect ion t ech n iqu e, car r ied ou t by
m e a n s o f a m e t a l l i c n e e d l e o r p l a s t i c c a t h e t e r. Ex t r av asat ion r at es cor r esp on d ed t o 1 0 . 0 % in t h e
group wit h m et allic access, against 1.2% in t he group w it h plast ic access, indicat ing a significant differ ence
i n e x t r a v a sa t i o n r a t e s b e t w e e n t h e t w o t y p e s o f in t r av en ou s dev ices ( p= 0 . 0 4 1 ) .
I t is equally im portant to com pare extravasation rat es according t o t he radiopaque subst ance inj ect ion
t echnique as, in recent years, t he use of t he inj ect ion
bom b has been related with increased occurrence levels of t his adv er se ev ent in int er nat ional lit er at ur e. This
relat ion is based on t he fact t hat aut om at ic inj ect ions adm inist er t he cont rast in const ant and st ronger flows
t han m anual inj ect ions( 8- 9).
I n or der t o analy ze ex t r av asat ion fr equency
according to the inj ection technique, the type of plastic v en o u s access w as m ai n t ai n ed co n st an t , sh o w i n g
extravasation in 1.2% of m anual inj ection cases, against 1.00% when using an inj ect ion bom b. Thus, t here was
n o st at ist ically im p or t an t d if f er en ce b et w een b ot h
t echniques ( p= 1.000) . However, it is em phasized t hat pat ien t s w h o r eceiv ed t h e au t om at ic in j ect ion w er e
previously assessed by the nursing team and that their venous net work was considered suit able t o receive t he
contrast agent through an inj ection bom b, while patients w it h higher r isk of ex t r av asat ion r eceiv ed a m anual
No sig n if ican t d if f er en ces in ex t r av asat ion
r at es w er e found bet w een gender s and age r anges. Ven ou s n et w or k f ragilit y w as pr esen t in 1 0 0 of t h e
3 1 7 s a m p l e p a t i e n t s , f i v e o f w h o m p r e s e n t e d e x t r a v a s a t i o n . Th i s c o r r e s p o n d s t o a 5 . 0 %
ex t r av asat ion r at e am ong pat ient s in t his condit ion. How ev er, t he differ ence w it h t he gr oup w it hout any
r isk fact or w as not st at ist ically significant ( p= 0.101) . Li t e r a t u r e( 2 , 8 - 1 0 ) a b o u t t h e o ccu r r e n ce o f
e x t r a v a sa t i o n r e f e r s t o r e se a r ch t h a t u se d so m e cr it er ia differ ent fr om t hose used in t his st udy, such
as t h e ex clu siv e u se of plast ic cat h et er s, ex clu siv e
u se of au t om at ic in j ect ion an d d if f er en t cr it er ia t o select t he research subj ect s. I n com paring t he result s
of t his st udy w it h int er nat ional r efer ences, at t em pt s w er e m ad e t o ad ap t r esu lt s f r om t h e HCPA t o t h e
cr it er ia u sed b y d if f er en t r esear ch er s, as sh ow n in Table 2.
On ly on e in t er n at ion al st u dy( 8 ) pr esen t ed a sign ifican t ly low er per cen t age t h an r esu lt s obt ain ed
at t he HCPA, alt hough ext ravasat ed cont rast volum es ranged from 3 t o 144 m l, wit h a m ean volum e of 41
m l. Th u s, alt h ou gh h igh er r at es w er e f ou n d in t h is
r esear ch , ex t r av asat ed v olu m es w er e sig n if ican t ly low er. This w as fundam ent al for t he non- occur r ence
o f d r a st i c co n seq u en ces i n t h e ex p o sed p a t i en t s. Mo r e o v e r, o t h e r s o u r c e s a l s o m e n t i o n h i g h e r
ex t r av asat ed v olu m es, r an gin g bet w een 3 an d 1 2 0 m l( 9), or do not specify t he ex t r av asat ed v olum es( 2).
Th e r ed u ced ex t r a v a sa t ed v o l u m es i n t h i s st u d y, corresponding t o less t han 10 m l, is at t ribut ed t o t he
fact t hat a nursing professional st ayed at t he pat ient ’s
s i d e d u r i n g t h e i n j e c t i o n , i d e n t i f y i n g s i g n s o f ex t r av asat ion at an ear ly st age and int er r upt ing t he
c o n t r a s t f l o w i n t i m e t o p r e v e n t m o r e s e v e r e com plicat ions in pat ient s ex posed t o t his ev ent .
Tab le 2 - Com p ar ison b et w een ex t rav asat ion r at es
found in int ernat ional publicat ions and in t his st udy
Anot her st udy( 10) m ent ioned in t able 2 t est ed
t he efficacy of an aut om at ic accessor y dev ice link ed w it h t h e con t r ast in j ect ion sit e, w h ich det ect s local
ex t r av asat ion , au t om at ically in t er r u pt s t h e in j ect ion of t he r adiopaque m edium and does not r equir e t he
h ealt h pr of ession al’s pr esen ce at t h e pat ien t ’s side d u r in g t h e in j ect ion . Th is r esear ch , car r ied ou t in
Philadelphia, USA, present ed t he highest ext ravasat ion r at e f ou n d in lit er at u r e, w it h ex t r av asat ed v olu m es
ranging bet ween 13 and 18 m l. Moreover, during t he st u d y, f a l se - p o si t i v e ca se s o ccu r r e d i n 2 . 4 % o f
inj ect ions, w hich pr obably pr ov ok ed t he unnecessar y
int er r upt ion of t he ex am .
FI NAL CONSI DERATI ONS
When associat ing t hese research result s wit h
av ailable int er nat ional r efer ences, som e div er gences appear ed in t er m s of cr it er ia used t o st udy adv er se
r eact ions t o iodinat ed cont r ast , such as t he select ion o f sa m p l e su b j e ct s a n d t h e si g n s a n d sy m p t o m s
con sider ed b y t h e r esear ch er.
As t o t h e st u dy su bj ect s, t h e fact t h at t h is sam ple ex clu siv ely con sist s of h ospit alized pat ien t s
suggest s a higher rat e of adverse event s t han in st udies including out pat ient s. Som e condit ions t hat ar e v er y
com m on am on g h osp it alized p at ien t s h av e alr ead y been associat ed w it h a t w o- t o f ou r f old in cr ease in
ch an ces f or t h e occu r r en ce of adv er se r eact ion s t o r adiopaque m edium , such as ex posur e t o sur ger ies,
invasive procedures or regular m edicat ion int ake during
t h e f iv e d ay s b ef or e t h e ex am( 1 2 ). Wit h r esp ect t o im m ediat e adverse react ions, t his research considered
v o m i t i n g , w h i l e i n t e r n a t i o n a l st u d i e s( 1 , 7 ) e x cl u d e vom it ing and include ot her sym pt om s, such as feeling
hot and pain in t he inj ect ion sit e. I n ot her words, st udy r e su l t s ca n o n l y b e co m p a r e d w h e n sa m p l e s i n
equiv alent healt h condit ions ar e used and w hen t he sam e research subj ect inclusion and exclusion crit eria
are adopt ed. However, due t o t he lack of inform at ion pr oduced in condit ions sim ilar t o t his st udy cont ex t ,
references were used t o provide param et ers t hat could
indicat e t he adequacy or inadequacy of local result s. I n t his st udy, im m ediat e adverse react ions t o
iodinat ed cont r ast occur r ed at a fr equency of 12.5% am ong pat ient s who received ionic m edium and 1.0%
am ong pat ient s exposed t o non- ionic cont rast . I nt ensit y levels of t hese event s were light and t hey were solved
sp on t an eou sly. Th ese r esu lt s ar e w it h in t h e lim it s quot ed in lit erat ure( 1,4,7), reflect ing fully accept able and
r a e y , s r o h t u A n o it a c il b u p f o n i d e s u a i r e ti r C l a n o it a n r e t n i e c n e r e f e r n i n o it a s a v a r t x E s e c n e r e f e r ) % ( n t a n o it a s a v a r t x E A P C H ) % ( n s 'r e h s i F t c a x E t s e T , g n a h C , e lr e d e F , n u g z O ,r e f n o C 8 9 9 1 (9)
f o e s u e v i s u l c x E d n a r e t e h t a c c it s a l p . b m o b n o it c e j n i ) 9 . 0 ( 6 0 1 5 : 8
4 2:195(1.0) p=0.707
, s b o c a J , m u a b n r i B 8 9 9 1 , z t o l g n a
L (8)
y fi c e p s t o n s e o D . e p y t r e t e h t a
c 41:6660(0.6) 7:317(2.2) p=0.005
, m u a b n r i B , n o s l e N , k c il G ,r a m z e h C 9 9 9 1 (10)
s t c e j b u s e l p m a S s r o t c a f k s ir t u o h ti w . n o it a s a v a r t x e r o f f o e s u e v i s u l c x E .r e t e h t a c c it s a l p ) 6 . 3 ( 0 0 5 : 8
1 0:66(0.0) p=0.250
, n a r h c o C , e r y a S , a e y m o B 1 0 0 2 (2)
f o e s u e v i s u l c x E d n a r e t e h t a c c it s a l p . b m o b n o it c e j n i ) 3 . 0 ( 1 7 3 5 5 : 7 5
sa f e r a t e s a cco r d i n g t o i n t e r n a t i o n a l r e f e r e n ce s.
Con seq u en t ly, it is con sid er ed t h at t h e st r at eg y of select iv ely u sin g n on - ion ic con t r ast , adopt ed at t h e
ser v ice w h er e t h is r esear ch w as car r ied ou t , of f er s adequat e securit y st andards t o client s, respect ing t he
i n s t i t u t i o n ’ s e c o n o m i c - f i n a n c i a l r e s t r i c t i o n s a n d r eflect ing an adequat e scr eening of r isk cases. This
d e m o n s t r a t e s t h a t n u r s i n g p r o f e s s i o n a l s h a v e sat isfact orily cont ribut ed t o t hese result s, t o t he ext ent
t hat t hey act ively part icipat e in t his decision process. What cont rast ext ravasat ion is concerned, t his
occur r ed in 2.2% of r adiopaque subst ance inj ect ions
t hr ough per ipher al v enous access, also accor ding t o p a r a m e t e r s f o u n d i n l i t e r a t u r e( 2 , 8 - 1 0 ). I n a l a r g e
m aj or it y of cases, ex t r av asat ed v olu m es r em ain ed under 10 m l, w it hout any com plicat ion der iv ing fr om
con t r ast ad m in ist r at ion in t h e ex t r av ascu lar sp ace. As t o t he m at er ial used t o est ablish v enous access,
t he use of plast ic cat het ers revealed t o be significant ly safer t han t he use of m et allic needles. I nt er nat ional
lit er at ur e alr eady m ent ions t his significant differ ence in ext ravasat ion risks when using bot h m at erials, and
n o o t h e r r e se a r ch w a s f o u n d t h a t u se d m e t a l l i c
needles. Thus, t he use of m et allic needles should be r eassessed , in v iew of t h e u n iv er sal u se of p last ic
access, and new st udies should be carried out t o t est
d i f f e r e n t m a t e r i a l s, co n si d e r i n g t h e co st - b e n e f i t
r elat ion of using alt er nat iv e dev ices.
Th e se r e co m m e n d a t i o n s, b a se d o n l o ca l
r e se a r ch d a t a , a s w e l l a s t h e a sse ssm e n t o f t h e r esp ect iv e in t er v en t ion s, ev id en ce t h e p r esen ce of
im pr ov em ent cy cles and qualit y m anagem ent in t he healt h w or k ar ea. Qualit y m anagem ent has becom e
fundam entally im portant in health service m anagem ent, to the extent that it em phasizes continuous im provem ent
t h r ou g h scien t if ic m et h od s an d d at a m on it or in g t o su p p or t d ecision m ak in g , w it h a v iew t o ach iev in g
m axim um client sat isfact ion and m inim izing risks t hat
can j eopardize t he int ended qualit y and securit y( 13- 14). Therefore, tom ography services should get to know the
occu r r en ce r at es of ad v er se ev en t s t o r ad iop aq u e m edium and the conditions in which they occur, so as to
obtain evidence to assess the respective care processes. The fact t hat t he int ensit y of adverse event s
was light and t hat t hey evolved well does not exclude t he need t o m aint ain t he work t eam always prepared
for em ergency care. Severe events cannot be previewed and can occur even when non- ionic cont rast agent is
used, including in low risk patients, and alternative im age
st u d ies t h at p r ov id e t h e sam e or b et t er d iag n ost ic inform at ion should be considered before adm inist ering
iodinat ed cont rast .
REFERENCES
1. Kat ayam a H, Yam aguchi K, Kozuka, T, Takashim a T, Seez P, Mat suura K. Adverse react ions t o ionic and nonionic cont rast m edia: a report from t he Japanese Com m it t ee on t he Safet y of Con t r ast Media. Radiology 1 9 9 0 Ju n e; 1 7 5 ( 3 ) : 6 2 1 - 8 . 2. Cochran ST, Bom yea K, Sayre JW. Trends in adverse event s af t er I V adm in ist r at ion of con t r ast m edia. AJR 2 0 0 1 Ju n e; 1 7 6 : 1 3 8 5 - 8 .
3 . Ju ch em BC, Dall’Ag n ol CM, Mag alh ães, AMM. Con t r ast e iodado em t om ografia com put adorizada: prevenção de reações ad v er sas. Rev Br as En f er m ag em 2 0 0 4 j an ei r o / f ev er ei r o ; 5 7 ( 1 ) : 5 7 - 6 1 .
4. Silva EA. Meios de cont rast e iodado. I n: Oliveira LAN, edit or. Assist ência à vida em r adiologia: guia t eór ico e pr át ico. São Paulo ( SP) : Colégio Brasileiro de Radiologia; 2000. p. 16- 114. 5 . Ma d d o x TG. Ad v e r se r e a ct i o n s t o co n t r a st m a t e r i a l : r ecogn it ion , pr ev en t ion , an d t r eat m en t . Am Fam Ph y sician 2 0 0 2 Oct o b er ; 6 6 ( 7 ) : 1 2 2 9 - 3 4 .
6 . M a r t i n W R. S a f e a n d a p p r o p r i a t e u s e o f i o d i n a t e d r adiogr aphic cont r ast agent s: is t her e a r eason t o use high-o sm high-o l a l i t y i high-o d i n a t ed chigh-o n t r a st a g en t s? Hhigh-o sp Ph a r m 2 0 0 1 Au g u st ; 3 6 ( 8 ) : 8 3 6 - 4 2 .
7 . Valls C, Andía E, Sánchez A, Mor eno V. Select ive use of low - osm olalit y cont rast m edia in com put ed t om ography. Eur Rad iol 2 0 0 3 Au g u st ; 1 3 ( 8 ) : 2 0 0 0 - 5 .
8 . Jacob s JE, Bi r n b au m BA, Lan g l ot z CP. Con t r ast m ed i a r ea ct i o n s a n d ex t r a v a sa t i o n : r el a t i o n sh i p t o i n t r a v en o u s in j ect ion r at es. Radiology 1 9 9 8 Nov em ber ; 2 0 9 ( 2 ) : 4 1 1 - 6 . 9. Feder le MP, Chang PJ, Confer S, Ozgun B. Fr equency and ef f ect s of ex t r av asat ion of ion ic an d n on ion ic CT con t r ast m edia du r in g r apid bolu s in j ect ion . Radiology 1 9 9 8 Mar ch ; 2 0 6 ( 3 ) : 6 3 7 - 4 0 .
1 0 . B i r n b a u m B A , N e l s o n RC, Ch e z m a r JL, Gl i c k S N . Ex t r av asat ion det ect ion accessor y : clinical ev aluat ion in 500 p at ien t s. Rad iolog y 1 9 9 9 Au g u st ; 2 1 2 ( 2 ) : 4 3 1 - 8 .
11. Bellin MF, Jakobsen JA, Tom assin I , Thom sen HS, Morcos SK. Con t r ast m ed iu m ex t r av asat ion in j u r y : g u id elin es f or p r ev en t ion an d m an eg em en t . Eu r Rad iol 2 0 0 2 Nov em b er ; 1 2 ( 1 1 ) : 2 8 0 7 - 1 2 .
12. Munechika H, Hiram at su Y, Kudo S, Sugim ura K, Ham ada C, Yam aguchi K, et al. A prospect ive survey of delayed adverse react ions t o iohexol in urography and com put ed t om ography. Eu r Rad iol 2 0 0 3 Jan u ar y ; 1 3 ( 1 ) : 1 8 5 - 9 4 .
13. Ant unes AV, Tr ev isan MA. Ger enciam ent o da qualidade: u t i l i z a ç ã o n o s e r v i ç o d e e n f e r m a g e m . Re v La t i n o - a m En f er m agem 2 0 0 0 j an eir o; 8 ( 1 ) : 3 5 - 4 4 .
14. Padilha KG. Ocorrências iat rogênicas na UTI e o enfoque de qu alidade. Rev Lat in o- am En f er m agem 2 0 0 1 set em br o; 9 ( 5 ) : 9 1 - 6 .
