Extravasation of Contrast Media

Frequency

The reported incidence of intravenous (IV) contrast media extravasation related to power injection for
CT has ranged from 0.1% to 0.9% (1/1,000 patients to 1/106 patients). Extravasation can occur during hand
or power injection. The frequency of extravasation is not related to the injection flow rate. Extravasation
occurring with dynamic bolus CT may involve large volumes of contrast media.

Initial Signs and Symptoms

Although most patients complain of initial swelling or tightness, and/or stinging or burning pain at the
site of extravasation, some experience little or no discomfort. On physical examination, the extravasation
site may be edematous, erythematous, and tender.

Sequelae of Extravasations

Extravasated iodinated contrast media are toxic to the surrounding tissues, particularly to the skin,
producing an acute local inflammatory response that sometimes peaks in 24 to 48 hours. The acute tissue
injury resulting from extravasation of iodinated contrast media is possibly related primarily to the hyper-
osmolality of the extravasated fluid. Despite this, the vast majority of patients in whom extravasations
occur recover without significant sequelae. Only rarely will a low-osmolality contrast media (LOCM)
extravasation injury proceed to a severe adverse event.

Most extravasations are limited to the immediately adjacent soft tissues (typically the skin and
subcutaneous tissues). Usually there is no permanent injury.

The most commonly reported severe injuries after extravasation of LOCM are compartment syndromes.
A compartment syndrome may be produced as a result of mechanical compression. A compartment syndrome
is more likely to occur after extravasation of larger volumes of contrast media; however, it also has been
observed after extravasation of relatively small volumes, especially when this occurs in less capacious areas
(such as over the ventral or dorsal surfaces of the wrist).

Less commonly, skin ulceration and tissue necrosis can occur as severe manifestations and can be
encountered as early as six hours after the extravasation has occurred.

A recent study has illustrated the infrequency of severe injuries after LOCM extravasation. In this
report by Wang and colleagues, only one of 442 adult LOCM extravasations resulted in a severe injury
(a compartment syndrome), although three other patients developed blisters or ulcerations that were
successfully treated locally.

Evaluation

Because the severity and prognosis of a contrast medium extravasation injury are difficult to determine
on initial evaluation of the affected site, close clinical follow-up for several hours is essential for all patients
in whom extravasations occur.

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There is no clear consensus regarding effective treatment for contrast medium extravasation. Elevation
of the affected extremity above the level of the heart to decrease capillary hydrostatic pressure and thereby
promote resorption of extravasated fluid is recommended, but controlled studies demonstrating the efficacy
of this treatment are lacking. There is no clear evidence favoring the use of either warm or cold compresses
in cases of extravasation. As a result there are some radiologists who use warm compresses and some who
use cold compresses. Those who have used cold have reported that it may be helpful for relieving pain at the
injection site. Those who have used heat have found it helpful in improving absorption of the extravasation
as well as in improving blood flow, particularly distal to the site.

There is no consistent evidence that the effects of an extravasation can be mitigated effectively by
trying to aspirate the extravasated contrast medium through an inserted needle or angiocatheter, or by local
injection of other agents such as corticosteroids or hyaluronidase.

Outpatients who have suffered contrast media extravasation should be released from the radiology
department only after the radiologist is satisfied that any signs and symptoms that were present initially
have improved or that new symptoms have not developed during the observation period. Clear instructions
should be given to the patient to seek additional medical care, should there be any worsening of symptoms,
skin ulceration, or the development of any neurologic or circulatory symptoms, including paresthesias.

Surgical Consultation

Surgical consultation prior to discharge should be obtained whenever there is concern for a severe
extravasation injury. An immediate surgical consultation is indicated for any patient in whom one or more
of the following signs or symptoms develops: progressive swelling or pain, altered tissue perfusion as
evidenced by decreased capillary refill at any time after the extravasation has occurred, change in sensation
in the affected limb, and skin ulceration or blistering. It is important to note that initial symptoms of a
compartment syndrome may be relatively mild (such as limited to the development of focal paresthesia).

In a previous edition of this manual, it was recommended that surgical consultation should be obtained
automatically for any large volume extravasations, particularly those estimated to be in excess of 100 ml;
however, more recently it has been suggested that reliance on volume threshold is unreliable and that the
need for surgical consultation should be based entirely on patient signs and symptoms. If the patient is
totally asymptomatic, as is common with extravasations in the upper arm, careful evaluation and appropriate
clinical follow-up are usually sufficient.

Patients at Increased Risk for Extravasations

Certain patients have been found to be at increased risk for extravasations, including those who cannot
communicate adequately (e.g., the elderly, infants and children, and patients with altered consciousness),
severely ill or debilitated patients, and patients with abnormal circulation in the limb to be injected. Patients
with altered circulation include those with atherosclerotic peripheral vascular disease, diabetic vascular
disease, Raynaud’s disease, venous thrombosis or insufficiency, or prior radiation therapy or extensive
surgery (e.g., axillary lymph node dissection or saphenous vein graft harvesting) in the limb to be injected.
Certain intravenous access sites (e.g., hand, wrist, foot, and ankle) are more likely to result in extravasation
and should be avoided if possible. In addition, injection through indwelling peripheral intravenous lines that
have been in place for more than 24 hours and multiple punctures into the same vein are associated with an
increased risk of extravasation.

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A severe extravasation injury is more likely to result from an extravasation in patients with arterial
insufficiency or compromised venous or lymphatic drainage in the affected extremity. In addition,
extravasations involving larger volumes of contrast media and those occurring in the dorsum of the hand,
foot, or ankle are more likely to result in severe tissue damage.

Documentation

All extravasation events and their treatment should be documented in the medical record, especially in
the dictated imaging report of the obtained study, and the referring physician should be notified.

Suggested Reading (Articles that the Committee recommends for further reading on this topic are provided here.)
1. Bellin MF, Jakobsen JA, Tomassin I, et al. Contrast medium extravasation injury: guidelines for prevention and management.
Eur Radiol 2002; 12:2807-2812.
2. Burd DA, Santis G, Milward TM. Severe extravasation injury: an avoidable iatrogenic disaster? Br Med J (Clin Res Ed) 1985;
290:1579-1580.
3. Cohan RH, Dunnick NR, Leder RA, Baker ME. Extravasation of nonionic radiologic contrast media: efficacy of conservative
treatment. Radiology 1990; 176:65-67.
4. Cohan RH, Ellis JH, Garner WL. Extravasation of radiographic contrast material: recognition, prevention, and treatment.
Radiology 1996; 200:593-604.
5. Cohan RH, Leder RA, Bolick D, et al. Extravascular extravasation of radiographic contrast media. Effects of conventional and
low-osmolar agents in the rat thigh. Invest Radiol 1990; 25:504-510.
6. Elam EA, Dorr RT, Lagel KE, Pond GD. Cutaneous ulceration due to contrast extravasation. Experimental assessment of
injury and potential antidotes. Invest Radiol 1991; 26:13-16.
7. 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.
8. Gault DT. Extravasation injuries. Br J Plast Surg 1993; 46:91-96.
9. Gothlin J. The comparative frequency of extravasal injection at phlebography with steel and plastic cannula. Clin Radiol 1972;
23:183-184.
10. Heckler FR. Current thoughts on extravasation injuries. Clin Plast Surg 1989; 16:557-563.
11. Jacobs JE, Birnbaum BA, Langlotz CP. Contrast media reactions and extravasation: relationship to intravenous injection rates.
Radiology 1998; 209:411-416.
12. Kim SH, Park JH, Kim YI, Kim CW, Han MC. Experimental tissue damage after subcutaneous injection of water soluble
contrast media. Invest Radiol 1990; 25:678-685.
13. Lang EV. Treatment to minimize skin or subcutaneous injury if extravasation occurs. AJR Am J Roentgenol 1996; 167:277-278.
14. Laurie SW, Wilson KL, Kernahan DA, Bauer BS, Vistnes LM. Intravenous extravasation injuries: the effectiveness of
hyaluronidase in their treatment. Ann Plast Surg 1984; 13:191-194.
15. McAlister WH, Kissane JM. Comparison of soft tissue effects of conventional ionic, low osmolar ionic and nonionic iodine
containing contrast material in experimental animals. Pediatr Radiol 1990; 20:170-174.
16. McAlister WH, Palmer K. The histologic effects of four commonly used media for excretory urography and an attempt to
modify the responses. Radiology 1971; 99:511-516.
17. Miles SG, Rasmussen JF, Litwiller T, Osik A. Safe use of an intravenous power injector for CT: experience and protocol.
Radiology 1990; 176:69-70.
18. Park KS, Kim SH, Park JH, Han MC, Kim DY, Kim SJ. Methods for mitigating soft-tissue injury after subcutaneous injection
of water soluble contrast media. Invest Radiol 1993; 28:332-334.
19. Pond GD, Dorr RT, McAleese KA. Skin ulceration from extravasation of low-osmolality contrast medium: a complication of
automation. AJR Am J Roentgenol 1992; 158:915-916.
20. Sinan T, Al-Khawari H, Chishti FA, Al Saeed OM, Sheikh M. Contrast media extravasation: manual versus power injector.
Med Princ Pract 2005; 14:107-110.
21. Sistrom CL, Gay SB, Peffley L. Extravasation of iopamidol and iohexol during contrast-enhanced CT: report of 28 cases.
Radiology 1991; 180:707-710.
22. Sum W, Ridley LJ. Recognition and management of contrast media extravasation. Australas Radiol 2006; 50:549-552.
23. Upton J, Mulliken JB, Murray JE. Major intravenous extravasation injuries. Am J Surg 1979; 137:497-506.
24. Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR. Frequency, management, and outcome of extravasation of nonionic
iodinated contrast medium in 69,657 intravenous injections. Radiology 2007; 243:80-87.

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