a b s t r a c t

Purpose: To characterize the management, outcomes, and emergency department (ED) length of stay (LOS) fol- lowing iodinated contrast media extravasation events in the ED. Methods: All ED patients who developed iodinated contrast media extravasation following contrast-enhanced CT from October 2007-December 2016 were retrospectively identified. Medical records were reviewed and management, complications, frequency of Surgical consultation, and ED LOS were quantified using descriptive statistics. The Wilcoxon rank sum test was used to compare ED LOS in patients who did and did not receive sur- gical consultation.

Results: A total of 199 contrast extravasation episodes occurred in ED patients during the 9-year study period. Of these, 42 patients underwent surgical consultation to evaluate the contrast extravasation event. No patient de- veloped progressive symptoms, compartment syndrome, or tissue necrosis, and none received treatment beyond supportive care (warm/cold packs, elevation, compression). Median ED LOS for patients who did and did not re- ceive surgical consultation was 11.3 h versus 9.0 h, respectively (p b 0.01).

Conclusion: Close observation and supportive care are sufficient for contrast extravasation events in the ED with- out concerning symptoms (progressive pain/swelling, altered tissue perfusion, sensory changes, or blistering/ul- ceration). Routine surgical consultation is likely unnecessary in the absence of these symptoms - concordant with the current American College of Radiology guidelines - and may be associated with longer ED LOS without impacting management.

(C) 2017

Introduction

Computed tomography (CT) has become an invaluable diagnostic tool in emergency departments (EDs) [1] and often involves the admin- istration of intravenous (IV) iodinated contrast to enhance visualization of vasculature and soft-tissue lesions. While the safety of iodinated con- trast media is well-established, uncommon potential adverse events resulting from their use include Allergic reactions, contrast-induced ne- phropathy, and extravasation at the peripheral venous injection site [2]. Iodinated contrast media extravasation has a reported incidence ranging from 0.2 to 1.2% [3-10]. Known risk factors include a distal ac- cess vein (hand or foot), smaller IV gauge (22G), older age, and prior ra- diation or surgery around the site of IV cannulation [3,5,11]. While

* Corresponding author at: Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Division of Emergency Imaging, 55 Fruit Street, Gray 2, Boston, MA 02114, USA.

E-mail address: [email protected] (A.M. Prabhakar).

¹ These authors contributed equally to this work and share joint first authorship.

many extravasation events are self-limited and can be managed conser- vatively, a small fraction (b 1%) have been known to result in morbid complications such as compartment syndrome or tissue necrosis [3,4]. The potential for these rare severe complications has compelled efforts to study the management and outcomes of contrast media extravasation.

Current management recommendations by the American College of Radiology (ACR) following an extravasation event include close clinical observation for several hours to watch for symptoms such as progres- sive pain or swelling, altered tissue perfusion, sensory changes in the af- fected limb, and blistering or ulceration [12]. Supportive measures such as the application of hot and cold packs or limb elevation are also com- monly employed for comfort, though evidence supporting their use is scant [12]. Additionally, previous editions of established guidelines

[13] suggested surgical consultation either above a certain volume of extravasation or when concerning symptoms develop, leading to fre- quent surgical consultations after extravasation events [3]. While mea- sures such as extended observation, supportive care, and surgical

https://doi.org/10.1016/j.ajem.2017.11.012

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J.D. Sonis et al. / American Journal of Emergency Medicine 36 (2018) 294-296 295

consultation are easily implemented in inpatients, providing them in the more temporally constrained ED setting poses unique concerns such as prolonging length of stay, altering patient disposition, and driv- ing up resource utilization. Given these issues, further study of contrast extravasation occurring in the ED setting is warranted to either rein- force or tailor management guidelines.

Therefore, the aim of this study was to characterize the manage- ment, outcomes, and effect on ED LOS for patients who experienced io- dinated contrast media extravasation during contrast-enhanced CT (CECT) in the ED.

Methods

Human subjects compliance

This retrospective, Health Insurance Portability and Accountability Act-compliant study was approved by the study institution’s Institu- tional Review Board, including waiver of patient consent.

Study site

The study was performed at a 999-bed quaternary care academic center with Level 1 trauma designation. Approximately 110,000 ED visits occur at the institution annually. There are two dedicated CT scan- ners within the ED and 24 h in-house emergency radiologist coverage.

Collection of patient data

The radiology department‘s electronic safety reporting system was queried to retrospectively identify all ED patients who experienced con- trast extravasation during a CECT examination from October 2007 to December 2016. The study period was selected based on the time point after which radiology department policy mandated documenta- tion by CT technologists on all events with an estimated extravasation volume over 10 ml. Inpatients who underwent imaging on the ED CT scanners were excluded.

Data on the estimated volume of contrast extravasation and the lo- cation of IV access, as documented by the CT technologist, was reviewed for each subject. Iopamidol (Isovue 370; Bracco Diagnostics Inc., Monroe Township, NJ) was the contrast agent used in all cases. Our ED data reporting system was used to obtain patient age and gender, ED LOS, and disposition from the ED. Two diagnostic radiologists and one emer- gency physician collectively reviewed the electronic medical records (EMR) for all patients, with particular attention to the ED provider note to determine whether treatment beyond supportive measures was administered, whether a surgical consultation was obtained to evaluate the extravasation, and whether any major complications de- veloped. Major complications were defined according to symptoms outlined in the ACR Manual on Contrast Media, including progressive pain or swelling, altered tissue perfusion, sensory changes in the affect- ed limb, and blistering or ulceration [12]. Supportive measures were de- fined as warm and cold packs, elevation, or compression. Uncertainty regarding classification of treatment was resolved by consensus.

Outcomes and analysis

The primary study outcomes were the rate of treatment beyond sup- portive measures, the rate of surgical consultation, and the association between surgical consultation and ED LOS. Secondary outcomes includ- ed the distribution of sites and estimatED volumes of contrast media ex- travasation. Descriptive statistics were used to assess the frequencies of collected data elements. Statistical tests included the Wilcoxon rank sum test to compare medians of nonparametric continuous variables (ED LOS) and the Pearson’s Chi-squared test to compare categorical var- iables (rate of surgical consultation). Analysis was conducted using Microsoft Excel 2015 (Redmond, WA) and SAS 9.4 (Cary, NC).

Results

Study population and extravasation characteristics

A total of 209 episodes of iodinated contrast media extravasation oc- curred in 209 ED patients during the 9 year, 3 month study period. Ten cases (5%) were excluded due to inability to locate adequate EMR docu- mentation during the chart Review process. The remaining 199 cases were included in our analysis. The mean patient age was 58 years (range 5-97 years), and 58% of patients were female. Data regarding the site of extravasation was available for 185 patients. The most com- mon sites were the antecubital fossa (150 patients, 81%) and forearm (17 patients, 9%), with other sites detailed in Table 1. The mean volume of estimated contrast extravasation was 60 ml (range 12-150 ml) based on data available for 193 patients; distribution of extravasation volumes is shown in Table 2.

Patient disposition and ED length of stay

Of the 199 documented contrast extravasation events, 42 (21%) prompted surgical consultation in the ED (Table 2). A significantly larger portion of patients with an extravasation volume of >= 50 ml received surgical consultation than those with an extravasation volume of b 50 ml (28% versus 7%, p b 0.001), and 88% of surgical consultations re- sulted from an extravasation volume >= 50 ml. No patient required surgi- cal intervention or treatment beyond supportive measures (warm/cold packs, elevation, compression).

One hundred thirteen (57%) patients were admitted to the hospital for indications unrelated to contrast media extravasation, 42 (21%) were discharged from the ED, and 37 (19%) were placed in the EDOU following their ED visit. No patient was admitted on the basis of contrast extravasation. Other dispositions are detailed in Table 2.

The mean ED LOS for all included patients was 11.1 h (median 9.5 h, range 0.8-43.3 h). Obtaining a surgical consultation was associated with a significantly longer ED LOS, with a median ED LOS for patients who did and did not receive surgical consultation of 11.3 h versus 9.0 h, respec- tively (p = 0.006). This trend persisted in the subgroup of patients who were ultimately discharged directly from the ED, where median ED LOS for those who did and did not receive surgical consultation was 13.8 and

7.9 h, respectively (p = 0.009).

Discussion

Our study reviewed contrast extravasation events over a 9-year pe- riod and found no examples of compartment syndrome or tissue necro- sis - the most feared sequelae of contrast media extravasation. Moreover, surgical consultation obtained in the ED did not alter man- agement of extravasation events but was associated with a longer ED LOS. In light of rising CT use in the ED [14] and growth in the provision of CT services at urgent care centers and free-standing acute care facili- ties [15], several implications of our report are germane to the emergen- cy medicine community.

Table 1

Characteristics of contrast media extravasation.

Variable Number of patients (%)

Site (n = 185)

Antecubital fossa 150 (81%)

Forearm 17 (9%)

Biceps 8 (4%)

Hand 5 (3%)

Wrist 5 (3%)

Volume of extravasation (n = 193)

10-49 ml 70 (36%)

50-99 ml 102 (53%)

100-150 ml 21 (11%)

296 J.D. Sonis et al. / American Journal of Emergency Medicine 36 (2018) 294-296

Table 2

Surgical consultation rate, patient disposition, and ED length of stay.

Variable Quantity (n = 199)

Frequency of surgical consultation Number of patients (%)

Surgical consult 42 (21%)

No surgical consult 157 (79%)

Disposition Number of patients (%)

Admitted (unrelated to extravasation)	113 (57%)
Discharged	42 (21%)
Placed in ED observation unit	37 (19%)
discharged against medical advice	2 (1%)
Moved to operating room	2 (1%)
interfacility transfer	2 (1%)
Death (unrelated to extravasation)	1 (0.05%)
Median emergency department length of stay Overall	Hours 9.5
Surgical consult (all)	11.3
No surgical consult (all)	9.0
Surgical consult (discharged from ED)	13.8
No surgical consult (discharged from ED)	7.9

The absence of a severe complication in our ED population is consis- tent with prior studies of contrast extravasation in primarily non-ED pa- tients, which found that severe complications occurred in b 1% of extravasation events [3,4] - indicating an overall incidence on the order of 1 in 10,000 contrast injections. The uniformly favorable out- comes in our cohort occurred despite substantial extravasation volumes (over 50 ml in 64% of patients). Nonetheless, given the morbidity of rare acute sequelae that may develop, Close monitoring of patients for mul- tiple hours following an extravasation event remains warranted, as per the current ACR guidelines [12]. Preventative measures may also be taken to reduce the risk of an extravasation event, including ensuring a lack of resistance to IV catheter flushing prior to injection; selecting an automated injection rate commensurate with the size of the peripheral vein and IV gauge (e.g. not exceeding 1.5 ml/s in distal extremity veins); and avoiding use of an IV that has been in place for over 24 h, when pos- sible [11,12].

Despite the lack of any morbid sequelae in our cohort, surgical con- sultation in the ED was obtained in 21% of patients with contrast extrav- asation, with no resulting Changes in management. The most likely impetus for frequent surgical consultation was the use of a defined ex- travasation volume threshold above which consultation was triggered, as suggested by the fact that 88% of consultations were obtained for a volume of >=50 ml. This may have represented the residuum of previous guidelines [13] recommending routine surgical consultation for extrav- asation volumes of over 50-100 ml regardless of symptoms, which like- ly continued to influence practice despite intervening alterations to the ACR manual - reiterating the well-known challenge of timely dissemi- nation of new practice guidelines. Patients in our study for whom surgi- cal consultation was obtained also had a longer median ED LOS, the tangible cost of which could be quantified in further analyses using methods such as time-driven activity based costing [16]. Our findings accord with prior studies demonstrating the exceedingly infrequent need for surgical intervention [3] and support the most recent ACR guidelines, which recommend surgical consultation for only the follow- ing indications: progressive pain or swelling, alterations in tissue perfu- sion, sensory changes in the affected extremity, or skin ulceration/ blistering [12]. Given the ubiquity of CT as a diagnostic tool, ED physi- cians are likely to encounter cases of contrast media extravasation and would benefit from knowledge of this guideline.

Our retrospective study has several limitations. First, the absence of

data on patients who obtained CECTs over the study period but did not experience extravasation precluded quantification of the incidence of contrast extravasation or analysis of Predisposing factors. However, given that our ED performs over 9000 CECTs annually, we are confident that our incidence of extravasation is very low (b 1%). Second, while the

local tissue response to contrast extravasation is known to peak within 48 h, we could not exclude the possibility of patients having had delayed sequelae from contrast extravasation and subsequently seeking care outside of our medical center. Third, the possibility of a selection bias ac- counting for the longer ED LOS in patients receiving surgical consulta- tion limited the ability to determine causality.

In conclusion, close observation and supportive care are sufficient for nearly all contrast extravasation events in the ED. Routine surgical consultation is likely unnecessary in the absence of progressive or concerning symptoms, and it may be associated with longer ED LOS without impacting management. Further work quantifying ED resource utilization attributable to contrast media-related adverse events could help refine associated Care pathways.

Source of support

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Conflict(s) of interest statements

Authors do not have any conflicts of interest.

References

1. Pandharipande PV, Reisner AT, Binder WD, et al. CT in the emergency department: a real-time study of changes in physician decision making. Radiology 2016;278(3): 812-21. https://doi.org/10.1148/radiol.2015150473.
2. Davenport MS, Cohan RH, Ellis JH. Contrast media controversies in 2015: imaging patients with Renal impairment or risk of contrast reaction. Am J Roentgenol 2015; 204(6):1174-81. https://doi.org/10.2214/AJR.14.14259.
3. Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR. Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69,657 in- travenous injections. Radiology 2007;243(1):80-7. https://doi.org/10.1148/radiol. 2431060554.
4. Dykes TM, Bhargavan-Chatfield M, Dyer RB. Intravenous contrast extravasation dur- ing CT: a national data registry and practice quality improvement initiative. J Am Coll Radiol 2015;12(2):183-91. https://doi.org/10.1016/j.jacr.2014.07.021.
5. Wienbeck S, Fischbach R, Kloska SP, et al. Prospective study of access site complica- tions of automated contrast injection with Peripheral venous access in MDCT. AJR Am J Roentgenol 2010;195(4):825-9. https://doi.org/10.2214/AJR.09.3739.
6. Cochran ST, Bomyea K, Sayre JW. Trends in adverse events after IV administration of contrast media. AJR Am J Roentgenol 2001;176(6):1385-8. https://doi.org/10.2214/ ajr.176.6.1761385.
7. Davenport MS, Wang CL, Bashir MR, Neville AM, Paulson EK. Rate of contrast mate- rial extravasations and allergic-like reactions: effect of extrinsic warming of low-os- molality iodinated CT Contrast material to 37 ?C. Radiology 2012;262(2):475-84. https://doi.org/10.1148/radiol.11111282.
8. Jacobs JE, Birnbaum BA, Langlotz CP. Contrast media reactions and extravasation: re- lationship to intravenous injection rates. Radiology 1998;209(2):411-6. https://doi. org/10.1148/radiology.209.2.9807567.
9. 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(3):637-40. https://doi.org/10.1148/radiology.206.3.9494479.
10. Hardie AD, Kereshi B. Incidence of intravenous contrast extravasation: increased risk for patients with deep brachial catheter placement from the emergency department. Emerg Radiol 2014;21(3):235-8. https://doi.org/10.1007/s10140-013-1185-x.
11. Nicola R, Shaqdan KW, Aran S, Prabhakar AM, Singh AK, Abujudeh HH. Contrast media extravasation of computed tomography and magnetic resonance imaging: management guidelines for the radiologist. Curr Probl Diagn Radiol 2016;45(3): 161-4. https://doi.org/10.1067/j.cpradiol.2015.08.004.
12. ACR. ACR manual on contrast media, v10.3. Reston, VA. https://www.acr.org/ Quality-Safety/Resources/Contrast-Manual; 2017, Accessed date: 5 July 2017.
13. ACR. ACR manual on contrast media, v5.0. Reston, VA; 2004.
14. Raja AS, Ip IK, Sodickson AD, et al. Radiology utilization in the emergency depart- ment: trends of the past 2 decades. Am J Roentgenol 2014;203(2):355-60. https:// doi.org/10.2214/AJR.13.11892.
15. Berger E. Freestanding emergency departments: burgeoning trend may relieve crowding but may drain away paying patients. Ann Emerg Med 2011;57(1): A22-4. https://doi.org/10.1016/j.annemergmed.2010.11.014.
16. Yun BJ, Prabhakar AM, Warsh J, et al. Time-driven activity-based costing in emergen- cy medicine. Ann Emerg Med 2016;67(6):765-72. https://doi.org/10.1016/j. annemergmed.2015.08.004.