For those of you with knowledge of what is happening with IV contrast injection in radiology, I have a few questions for you.
1. What is your best guesstimate of what percentage of contrast injection is given with a power injector vs what percent is given for other procedures where power injection is not needed?
2. What are the common challenges you see with safe contrast injection, with or without power injection?
3. What problems, issues, or concerns do you have about insertion, use of and maintenance of IV catheters of all types in the radiology dept?
4. Any other comments that you can think of.
Thanks, Lynn
Response to #2 with power injection. Not having the proper supplies or protocol to use a pre-exisiting port for a power injection procedure. So, its just not used and another line is placed, or perhaps unknowingly the wrong supply is used, such as a huber needle that is not for power.
Response to #3 : Vascular depletion due to lack of knowledge....patient has a pre-exisiting central line (all types). Staff unsure, seem timid about using because they don't want to do the wrong thing to the pt's line.
Kathleen Wilson, CRNI
1. A very large % require the use of a power injection . I would guesstimate about 85%. I have the understanding they want to get good pictures from the get go and do not like to repeat the scan. We seem to do a lot of Chest CT scans where I work.
2. Challenges:
* lack of assessment skills in determining an adequate PIV for safe contrast injection. They seem very trusting of the site and I want them to check the the date of insertion..assess patency..assess location and the general quality of the vein being used to assess if it is suitable for power injection. I do have to say they are aware of optimal locations almost to a fault. I have had this discussion so many times with techs. They ALWAYS ask for an ACF PIV..and I rarely place them exactly there. I tend to go just below so tip or hub not at an area of flexion. SOME think the only place that can be used is the ACF if using a PIV..have had that discussion as well and have told them what their own guidelines say..FA ok.if vein is good and large and can handle the power injection. I have also seen some RNs making attempts at ACF sites below a venipunture they just did or lab just did..so we see extravastions above the established IV site. IF a PIV is placed in the ACF and patient is an inpatient I can not get anyone to take it out..IVT always has to go back and d/c it if we had to use the ACF or use US.
* OFTEN the patient has a CVC or port that has power injectable capability and they do NOT use it..still requsting PIVs . We often find out after the
fact
* IV therapy is OFTEN needed for starts. I think this is a good thing but it is time consuming for our very busy team since they want them ASAP to
to prevent the back-up of patients. I have bugun to mark on my starts for CT scan power injection that it was started by an IV nurse.
* It seems as if there is inconsistant assessment of the the extension set to see if it can be used for power injection. Even though we have done
some training I still see the incorrect extension used. Also many do not know they can not use the intima...some do know.
* If an extravastion occurs there is inconsistent treatment given..IF AT ALL. Some inpatients are sent back to their rooms without any treatment
If report was given about the extravastion many do not know how to treat and assess for complications. Many do not know the difference
an infiltration or extravastion and do not know that contrast media can cause tissue necrosis. Some nurses do call us and we review how to assess
the tissue..how to assess for compartment syndrome..make sure the radiologist has seen it..plastic surgery consult if needed... etc
Now for power injectable CVCs...ports and PICCs...lots of issues..though things are better in this area. One time a patient waited for 2 days to get
a chest CT..pt was getting their IV therapies via an accessed port but no one could get a PIV..so I pulled up the CXR..saw the power port and
accessed with a power loc needle...problem solved. We have seen some malpositioned PICCs post power injection. We have seen our silicone
PICCs used and then subsequently rupture/fracture during injection. We have had thrombotic occlusions post power injection due to no flushing
done after the injection.
3. Problems..Issues..Concerns...Some I have addressed above....others include..extension set rupture.....inadequate follow-up after extravastion esp with
outpatients.......use of a catheter that should not be used per the IFUs.....use of PIVs that are no longer in the vein.....sometimes a difficult IV
start becomes even more difficult b/c of space issues..pt is already on the table or gurney...difficult for pt to keep their arm out since they are not on
bed...if US guided PIV is used the extravastion is often difficult to detect b/c of the depth of the vein.
I worked in the Radiology department of a community hospital for 2 years, then as a clinical specialist for a manufacturer of an MRI safe infusion pump. I am currently on the board of the Association for Radiological and Imaging Nursing, and have been a member since 2005.
1) The majority of injections of contrast are done with a high pressure, or power injector. If a test is ordered with contrast, that is the first choice for contrast delivery. This is due to the timing needed to get the contrast to the area being imaged, in both CT and MRI. The exceptions would be hand injection for small children, and if a pressure/power injectable IV access is not available. Those are typically the ONLY exceptions if a test is ordered with contrast. In some cases, the test is done without contrast instead of hand injecting if no access is available, because hand injection would not benefit the scan. This results in poorer images
2) In most hospitals, it is the Radiology tech injecting the contrast. Not all are properly trained in indentifcation of power injectable catheters, insertion of peripheral catheters, or care of catheters. Better training and education is needed to ensure catheters are flushed properly before and after injection, caps are cleaned properly or removed and replaced properly, and aseptic technique is used when inserting a peripheral IV or accessing a catheter or port.
3) See above
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
Luckily most of the contrasts today are isotonic compared to the old days of hyertonicity
Infiltrations and nerve injury are still an issue in catheter placement and contrast injection
Antecubital placements are still the first choice as they are the easiest to do
Placements are starting to be done by non liscesned personnel depending on the state and facility
Placement of a huber needle for port access is still likely to be performed by an RN but that is also starting to slowly change in some institutions
Warming of contrast injection may not always bei performed and that is a pre-requisite to safe administration in most company instructions for use.
Obtaining a blood return to ascertain the line is patent and flushes without occlusion imay not always be done and that is a safety concern for any vascular access device being used for power injection
Identification of a power injectable port may not be performed with two patient identifiers. Especially if the patient comes down accessed with a power injectable huber needle in place. Everyone in the healthcare systems has to take accountability for the two patient identifiers before assuming one has a power injectable device.
For your research Lynn those are the things off the top of my head I can think of
Kathy Kokotis
Bard Access Systems