When Contrast Extravasates:
What Do I Do?
Richard H. Cohan,
M.D. and James H. Ellis, M.D.
36-year-old female with vague abdominal pain referred for an
abdominal CT examination. During
the contrast injection, approximately 150 ml of nonionic contrast material
extravasated into the left antecubital fossa.
47-year-old neurotic radiologist who just happened to be assigned to CT
that day. The radiologist did not
start the IV line (a technologist did), but was called to see the patient. He
applied warm compresses and called the patients referring physician before
sending the patient home with instructions to return should her swelling
worsen. The radiologist never heard anything further.
…for two years until the
Allegations by the defendant:
The patient was not informed of the possibility of
extravasation prior to injection and
to possible adverse outcomes from an extravasation.
When the IV line was being inserted, the patient told the
technologist that she
was having a lot of pain and
demanded that they remove the angiocatheter.
The technologists did not respond to her, but proceeded
Once the contrast material was injected, that patient screamed
in pain for over
two minutes, during which time she
was ignored by the technologists, who assured her that everything was fine.
Almost all of the contrast material had been injected before the technologist
removed the needle and called a doctor.
No physician ever came to evaluate the patient and she was
sent home with no
She went to a local emergency room later that evening with
swelling and absent pulses in her
extremity. Emergency surgery was performed.
The patient has had constant pain since that time. She has had
for ulnar nerve decompression and
she has been in physical therapy for many months without improvement.
Issues to be discussed:
Should the radiologist have done anything differently?
Could the episode have been prevented? What can be done to minimize
risk of patient
discomfort and injury?
What is the typical outcome in patients with large volume
Is the radiologist liable?
Could the litigation have been avoided? What can be done to
litigation? Some possible outcomes of litigation will be discussed.
Facts about contrast media extravasation
Frequency: The number of reported contrast
media extravasations during CY has increased markedly over the past few years
as high-rate dynamic bolus techniques with automated injector have become
widely used. Currently, extravasations are detected in 0.25-0.9% of all
patients referred for contrast-enhanced CT [1-3]. While the frequency of severe
injuries after contrast extravasation during CT is unknown, such injuries are
extremely uncommon. In three series including over 30,000 patients, all 135
extravasations (some involving ionic contrast material) resolved without
long-term sequelae [1-3].
Injuries after extravasation of ionic agents:
Ionic contrast material has much greater skin and subcutaneous toxicity than
nonionic contrast material. Skin ulceration and necrosis are occasionally
encountered. As with any large volume extravasation, compartment syndromes can
occur. Some patients develop chronic scarring and long-term pain.
Reconstructive surgery may be required. Reports of adverse sequelae have
appeared in the radiologic and plastic surgery literature. .
Injuries after extravasation of nonionic agents: There have only been three published reports of injuries produced by
extravasated nonionic contrast media. In one, a 30 cm
2 area of ulceration developed in a comatose patient after
extravasation of 150 ml of iohexol from an upper extremity injection site .
The extravasation occurred while an automatic blood pressure cuff (higher on
the arm) was inflated. Only topical treatment was required in this patient. In
the second instance, a compartment syndrome resulted form injection of over 180
ml of iohexol- 350 agent into a patient’s forearm . Emergency fasciotomy was
performed. The third case involved a 60 ml extravasation of iohexol- 320 into
the dorsum of the hand during a CT which produced swelling and blistering .
A compartment syndrome also developed and emergency fasciotomy was required.
Although each reaction was significant, in no case was debridement or
reconstructive surgery required.
There have been anecdotal unpublished reports of
compartment syndromes resulting from extravasation of small volumes of nonionic
contrast material (10-20 ml), as well as of chronic pain after a large volume
extravasation of nonionic contrast material (RHC, personal communications).
factors for extravasations: Some patients are more likely to develop
extravasations. This includes patients at extremes of age or who are
unconscious . These individuals are less likely to complain of injection
site pain. Extravasations are also more probable in patients injected through
small peripheral veins, after injection through metal needles (such as
butterflies) rather than plastic cannulae, when tourniquets are not released,
such as may be the case during lower extremity venography, and after injection
through an indwelling intravenous line . Multiple attempts to establish
venous access through the same vein can also be a problem. Contrast material
that is properly instilled through a peripheral vein may occasionally leak out
of a defect just created more centrally .
factors for severe extravasation injuries: Patients with
impaired circulation, such as those with sever atherosclerosis, diabetes
mellitus, connective tissue disease, prior radiation to an injection site, or
central or peripheral venous thrombosis, are at increased risk for a severe
complication from an extravasation . Severe extravasation injuries are also
more common in the elderly or very young, possibly because extravasations are
more frequent in these patients . Larger volume extravasations are more
likely to cause tissue damage . Significant morbidity from extravasation is
also more likely to result when injections are performed into the dorsum of the
hand, foot, or ankle, rather than the antecubital fossa .
Recommendations: We recommend that all radiologists who use radiographic contrast
material have a policy in place to deal with extravasation injuries. This
policy should take into consideration the reduced toxicity of nonionic contrast
material and the likelihood that most extravasation injuries heal without the
need for surgery. The policy should be developed in consultation with whichever
physicians would have to treat a patient with a major extravasation injury. The
policy should include provisions for recording the severity of an extravasation
injury and for close patient monitoring and follow-up. The policy should also
be designed to help minimize the duration of patient discomfort. Patient should
not be sent home without instructions about what to do if their symptoms do not
resolve. They should instead feel confident that this complication is being
properly handled. Our policy is reviewed in detail elsewhere , but is
If an extravasation occurs, the affected extremity is
elevated above the level of the heart. Ice packs are applied. The patient is
monitored in the radiology department for two to four hours. The extravasation
site is periodically inspected for increased swelling or pain, altered tissue
sensation or perfusion, or skin ulceration or blister, The Plastic Surgery
service is consulted immediately if a patient develops these signs or symptoms.
In addition, Plastic Surgery consultation is also requested for any
extravasated volume estimated to exceed the arbitrarily chosen threshold
volumes of 30 ml of conventional ionic and 100 ml of nonionic contrast media.
The radiologist should notify a referring physician whenever the volume of
extravasation contrast material is > 5 ml.
If patient symptoms are mild and do not worsen over time,
the patient can be discharged after two to four hours. This can be done even if
large volume extravasations have occurred (after Plastic Surgery has been
consulted). The patient is given a telephone number to call if his or her
status changes. A physician or nurse also phones the patient daily until signs
and symptoms have completely disappeared. During these telephone calls the
patient is asked whether his or her pain is increasing, and whether there is
any blistering, ulceration, color, temperature, or consistency change at the
injured area. If the patient answers affirmatively to any of these questions,
he or she may be asked to return to the hospital for further evaluation.
Documentation of this entire process is required. A contrast extravasation
report form is complete by the physician, nurse, and/or technologist who
witnesses the extravasation. The information collected during follow-up
telephone calls is recorded on an additional sheet of paper (which also lists
the questions that the calling nurse or radiologist is expected to ask). This
sheet of paper is then added to the patient’s medical record.
of MR Contrast agents: Animal studies have demonstrated that
gadopentetate dimeglumine, the most widely used MR contrast agent, is capable
of producing skin ulceration and necrosis [8,9], although it is better
tolerated than conventional ionic radiographic contrast media. Since lower
volumes of MR agents (in comparison with iodinated contrast media) are usually
injected, serous injuries resulting from extravascular injections of
gadopentetate should be much less frequent than injuries after extravasation of
iodinated radiographic contrast media.
1. Bullard MA, Cohan RH, Ellis JH, Jan SH, Francis IR, Dunnick NR.
Extravasation of intravenous contrast material: incidence,
outcome. Academic Radiol 1997; 4:711-718.
2. Federle MP, Chang PJ, Confer S, Ozgun B. Frequency and effects of
extravasation of ionic and nonionic CT contrast media during rapid bolus
injection. Radiology 1998; 206:637-640.
3. Jacobs JE, Bimbaum BA, Langlotz CP. Contrast media reactions and
extravasation: relationship to intravenous injection rates. Radiology 1998;
4. Cohan RH, Ellis JH, Garner WM. Extravasation of radiographic contrast
material: recognition, prevention, and treatment. Radiology 1996; 200: 593-604.
5. Pond GD, Dorr RT, McAleese KA.
Skin ulceration from extravasation of low-osmolality contrast medium: a
complication of automation. AJR 1992; 158: 915-916.
6. Memolo M, Dyer R, Zagoria RJ. Extravasation injury with nonionic
contrast material. AJR 1993; 160: 203.
7. Young RA. Injury due to extravasation of nonionic contrast material
(letter). AJR 1994; 162: 1499.
8. McAlister WH, McAlister VI, Kissane JM. The effect of GD-dimeglumine on
subcutaneous tissues; a study with rats. AJNR 1990; 11:325-327.
9. Cohan RH, Leder RA, Herzberg AJ, Hedlund LW, Wheeler CT, Beam CA, Nadel
SN, Dunnick NR. Extravascular toxicity of two magnetic resonance contrast
agents: preliminary experience in the rat. Invest Radiol 1991; 26: 224-226.