Diagnostic computed tomography (CT) imaging, utilizing intravenous (IV) contrast administration, has become increasingly common. Potential IV contrast-associated complications include local skin and soft tissue reactions due to extravasation. The goal of this study is to describe the risk of contrast extravasation based on IV catheter anatomic location in patients receiving contrast-enhanced CT imaging.
The study was conducted as a retrospective cohort study of patients receiving contrast-enhanced CT imaging performed over a 26-month period at a single institution. The rate of contrast extravasation was calculated by IV catheter vessel anatomic location and compared by relative risk (RR) and absolute risk reduction (ARR).
Of 17,767 contrast administrations for CT imaging studies performed, 14,558 met study inclusion criteria. Forty-nine (0.34%) extravasation events were identified. Forty-one (0.28%, 95% CI 0.21–0.39%) extravasation events were observed in 14,275 peripheral IV catheters placed in a non-upper arm location. Eight (2.8%, 95% CI 1.3–5.3%) extravasation events were observed in 283 IV catheters placed, most commonly with point-of-care ultrasound (POCUS) guidance, in upper arm vessels (RR 10.1, 95% CI 4.69–21.8). Non-upper arm located IV catheters were associated with an ARR of 2.54% (95% CI 0.61–4.47%) when compared to upper arm catheters.
IV catheter placement in upper arm vessels is associated with a relatively minimal increase in extravasation risk when compared to catheters placed in a non-upper arm location. In patients without alternative available peripheral vascular access, POCUS-guided upper arm IV cannulation may be an appropriate approach.
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Berdahl CT, Vermeulen MJ, Larson DB, Schull MJ (2013) Emergency department computed tomography utilization in the United States and Canada. Ann Emerg Med 62(5):486–494. https://doi.org/10.1016/j.annemergmed.2013.02.018
Davenport MS, Cohan RH, Ellis JH (2015) Contrast media controversies in 2015: imaging patients with renal impairment or risk of contrast reaction. AJR Am J Roentgenol 204(6):1174–1181. https://doi.org/10.2214/AJR.14.14259
Federle MP, Chang PJ, Confer S, Ozgun B (1998) Frequency and effects of extravasation of ionic and nonionic CT contrast media during rapid bolus injection. Radiology. 206(3):637–640
Wienbeck S, Fischbach R, Kloska SP et al (2010) Prospective study of access site complications of automated contrast injection with peripheral venous access in MDCT. AJR Am J Roentgenol 195(4). https://doi.org/10.2214/AJR.09.3739
Jacobs JE, Birnbaum BA, Langlotz CP (1998) Contrast media reactions and extravasation: relationship to intravenous injection rates. Radiology. 209(2):411–416
Heshmatzadeh Behzadi A, Farooq Z, Newhouse JH et al (2018) MRI and CT contrast media extravasation. Medicine (Baltimore) 97(9). https://doi.org/10.1097/MD.0000000000010055
Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR (2007) Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69,657 intravenous injections. Radiology. 243(1):80–87
ACR. ACR manual on contrast media, v10.3. Reston, VA. https://www.acr.org/Quality-Safety/Resources/Contrast-Manual; 2017, Accessed date: 29 December, 2018
Dykes TM, Bhargavan-Chatfield M, Dyer RB (2015) Intravenous contrast extravasation during CT: a national data registry and practice quality improvement initiative. J Am Coll Radiol 12(2):183–191. https://doi.org/10.1016/j.jacr.2014.07.021
Sonis JD, Gottumukkala RV, Glover M 4th et al (2018) Implications of iodinated contrast media extravasation in the emergency department. Am J Emerg Med 36(2):294–296. https://doi.org/10.1016/j.ajem.2017.11.012
Vinod K, Shravan R, Shrivarthan R et al (2016) Acute compartment syndrome of hand resulting from radiographic contrast iohexol extravasation. J Pharmacol Pharmacother 7(1):44. https://doi.org/10.4103/0976-500X.179353
Tonolini M, Campari A, Bianco R (2012) Extravasation of radiographic contrast media: prevention, diagnosis, and treatment. Curr Probl Diagn Radiol 41(2):52–55. https://doi.org/10.1067/j.cpradiol.2011.07.004
Kingston RJ, Young N, Sindhusake DP, Truong M (2012) Study of patients with intravenous contrast extravasation on CT studies, with radiology staff and ward staff cannulations. J Med Imaging Radiat Oncol 56(2):163–167. https://doi.org/10.1111/j.1754-9485.2012.02355.x
Hardie AD, Kereshi B (2014) Incidence of intravenous contrast extravasation: increased risk for patients with deep brachial catheter placement from the emergency department. Emerg Radiol 21(3):235–238. https://doi.org/10.1007/s10140-013-1185-x
Plumb AAO, Murphy G (2011) The use of central venous catheters for intravenous contrast injection for CT examinations. Br J Radiol 84(999):197–203. https://doi.org/10.1259/bjr/26062221
Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D (1999) Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med 34(6):711–714
Rupp JD, Ferre RM, Boyd JS, Dearing E, McNaughton C, Liu D, Jarrell KL, McWade C, Self WH (2016) Extravasation risk using ultrasound-guided peripheral intravenous catheters for computed tomography contrast administration. Acad Emerg Med 23(8):918–921. https://doi.org/10.1111/acem.13000
Costantino TG, Parikh AK, Satz WA, Fojtik JP (2005) Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med 46(5):456–461
Egan G, Healy D, O’Neill H et al (2012) Ultrasound guidance for difficult peripheral venous access: systematic review and meta-analysis. Emerg Med J 30(7):521–526. https://doi.org/10.1136/emermed-2012-201652
Stolz LA, Stolz U, Howe C, Farrell IJ, Adhikari S (2015) Ultrasound-guided peripheral venous access: a meta-analysis and systematic review. J Vasc Access 16(4):321–326. https://doi.org/10.5301/jva.5000346
Benkhadra M, Collignon M, Fournel I et al (2012) Ultrasound guidance allows faster peripheral IV cannulation in children under 3 years of age with difficult venous access: a prospective randomized study. Paediatr Anaesth 22(5):449–454. https://doi.org/10.1111/j.1460-9592.2012.03830.x
Doniger SJ, Ishimine P, Fox JC, Kanegaye JT (2009) Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients. Pediatr Emerg Care 25(3):154–159. https://doi.org/10.1097/PEC.0b013e31819a8946
Blaivas M, Lyon M (2006) The effect of ultrasound guidance on the perceived difficulty of emergency nurse-obtained peripheral IV access. J Emerg Med 31(4):407–410
Schoenfeld E, Boniface K, Shokoohi H (2011) ED technicians can successfully place ultrasound-guided intravenous catheters in patients with poor. Am J Emerg Med 29(5):496–501. https://doi.org/10.1016/j.ajem.2009.11.021
Brannam L, Blaivas M, Lyon M, Flake M (2004) Emergency nurses’ utilization of ultrasound guidance for placement of peripheral intravenous lines in difficult-access patients. Acad Emerg Med 11(12):1361–1363
Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF (2015) Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev 1:CD011447. https://doi.org/10.1002/14651858.CD011447
Gregg SC, Murthi SB, Sisley AC, Stein DM, Scalea TM (2010) Ultrasound-guided peripheral intravenous access in the intensive care unit. J Crit Care 25(3):514–519
Buijs SB, Barentsz MW, Smits MLJ et al (2017) Systematic review of the safety and efficacy of contrast injection via venous catheters for contrast-enhanced computed tomography. Eur J Radiol Open 4:118–122. https://doi.org/10.1016/j.ejro.2017.09.002
Ge X, Cavallazzi R, Li C, Pan SM, Wang YW, Wang FL (2012) Central venous access sites for the prevention of venous thrombosis, stenosis and infection. Cochrane Database Syst Rev 14(3):CD004084. https://doi.org/10.1002/14651858.CD004084.pub3
Eisen LA, Narasimhan M, Berger JS, Mayo PH, Rosen MJ, Schneider RF (2006) Mechanical complications of central venous catheters. J Intensive Care Med 21(1):40–46
Odendaal J, Kong V, Sartorius B, Liu TY, Liu YY, Clarke DL (2017) Mechanical complications of central venous catheterisation in trauma patients. Ann R Coll Surg Engl 99(5):390–393. https://doi.org/10.1308/rcsann.2017.0022
Smit JM, Raadsen R, Blans MJ, Petjak M, van de Ven P, Tuinman PR (2018) Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: a systematic review and meta-analysis. Crit Care 22(1):65. https://doi.org/10.1186/s13054-018-1989-x
Struck MF, Fakler JKM, Bernhard M, Busch T, Stumpp P, Hempel G, Beilicke A, Stehr SN, Josten C, Wrigge H (2018) Mechanical complications and outcomes following invasive emergency procedures in severely injured trauma patients. Sci Rep 8(1):3976. https://doi.org/10.1038/s41598-018-22457-9
Tsotsolis N, Tsirgogianni K, Kioumis I, Pitsiou G, Baka S, Papaiwannou A, Karavergou A, Rapti A, Trakada G, Katsikogiannis N, Tsakiridis K, Karapantzos I, Karapantzou C, Barbetakis N, Zissimopoulos A, Kuhajda I, Andjelkovic D, Zarogoulidis K, Zarogoulidis P (2015) Pneumothorax as a complication of central venous catheter insertion. Ann Transl Med 3(3):40. https://doi.org/10.3978/j.issn.2305-5839.2015.02.11
Hwang B-Y, Kim E, Kim W-S et al (2014) Hemorrhagic shock occurring due to a concealed hematoma after insertion of a subclavian venous catheter in a patient undergoing anticoagulation therapy: a case report. Korean J Anesthesiol 67(5):358. https://doi.org/10.4097/kjae.2014.67.5.358
Parikh G, Shonde S, Shah R et al (2014) A case of guidewire embolism during central venous catheterization: Better safe than sorry! Indian J Crit Care Med 18(12):831. https://doi.org/10.4103/0972-5229.146340
Ananthakrishnan G, White RD, Bhat R et al (2012) Inadvertent subclavian artery cannulation: endovascular repair using a collagen closure device—report of two cases and review of the literature. Case Rep Vasc Med 2012:1–4. https://doi.org/10.1155/2012/150343
Katyal N, Korzep A, Newey C (2018) Inadvertent central arterial catheterization: an unusual cause of ischemic stroke. J Neurosci Rural Pract 9(1):155. https://doi.org/10.4103/jnrp.jnrp_460_17
Nath M, Gupta S, Chakrabarty A (2010) Extravasation of catheter tip following central venous catheterisation: a near fatal complication. Indian J Anaesth 54(6):572–573. https://doi.org/10.4103/0019-5049.72651
Schummer C, Sakr Y, Steenbeck J et al (2010) Risk of extravasation after power injection of contrast media via the proximal port of multilumen central venous catheters: case report and review of the literature. RöFo. 182(01):14–19. https://doi.org/10.1055/s-0028-1109742
Gottlieb M, Sundaram T, Holladay D, Nakitende D (2017) Ultrasound-guided peripheral intravenous line placement: a narrative review of evidence-based best practices. West J Emerg Med 18(6):1047–1054. https://doi.org/10.5811/westjem.2017.7.34610
Panebianco NL, Fredette JM, Szyld D, Sagalyn EB, Pines JM, Dean AJ (2009) What you see (sonographically) is what you get: vein and patient characteristics associated with successful ultrasound-guided peripheral intravenous placement in patients with difficult access. Acad Emerg Med 16(12):1298–1303. https://doi.org/10.1111/j.1553-2712.2009.00520.x
Witting MD, Schenkel SM, Lawner BJ et al (2010) Effects of vein width and depth on ultrasound-guided peripheral intravenous success rates. J Emerg Med 39(1):70–75. https://doi.org/10.1016/j.jemermed.2009.01.003
Elia F, Ferrari G, Molino P, Converso M, de Filippi G, Milan A, Aprà F (2012) Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg Med 30(5):712–716. https://doi.org/10.1016/j.ajem.2011.04.019
Pandurangadu AV, Tucker J, Brackney AR et al (2018) Ultrasound-guided intravenous catheter survival impacted by amount of catheter residing in the vein. Emerg Med J 35(9):550–555. https://doi.org/10.1136/emermed-2017-206803
The study authors would like to acknowledge WenShan Lin, Chris Gignac, and Lara Johnston for assistance with data collection.
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Stowell, J.R., Rigdon, D., Colglazier, R. et al. Risk of contrast extravasation with vascular access in computed tomography. Emerg Radiol (2020). https://doi.org/10.1007/s10140-020-01752-x
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