Using Contrast Media in Breast Imaging

“Contrast media are among the safest of all pharmaceutical products available today”, said Eva Maria Fallenberg from Munich, Germany. The rate of adverse reactions to CM is extremely low, “but they do occur, just as with every pharmaceutical product”, she said.

 

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Adverse Reactions to Contrast Media are rare

The risk of death is extremely low for both iodine-based and gadolinium (Gd)-based contrast media (CM):

Gd-based CM:    1/100.000 procedures

Iodine-based CM:       0.9/100.000 procedures

The rates of adverse events related to the administration of CM are

Gd-based CM:   15/100.000 procedures

Iodine-based CM:       157/100.000 procedures

The risk of post-contrast AKI (Acute Kidney Injury) is increased

  • After intra-arterial CM administration
  • With high osmolality CM
  • When large CM doses are administered
  • After multiple CM administrations

According to the ESUR Guidelines on Contrast Agents v10.0, patient-related risk factors for post-contrast AKI are

  • eGFR (estimated Glomerular Filtration Rate) less than 45 ml/min/1.73 m² before intra-arterial CM administration
  • eGFR less than 30 ml/min/1.73 m² before intravenous CM administration
  • Known or suspected acute renal failure
  • Other factors such as age over 70 years, diabetic nephropathy, dehydration or congestive heart failure increase the likelihood of developing AKI.

“You have to check your patient’s medication for potential interactions”, warned Fallenberg with regard to drugs like Metformin, Beta-Blockers and other substances.

Contrast in Breast MRI Examinations

As Sardanelli et al. showed in their multicenter trials (GEMMA I and GEMMA II – Invest Radiol 2016), the sensitivity of contrast-enhanced preoperative breast MRI in patients with proven breast cancer (83-95%) outperforms that of mammography (68-73%) and non-enhanced MRI (37-73%). “So far, we do need contrast agents for MRI of the breast”, said Fallenberg.

Who Requires Renal Function Tests?

Renal functional tests should be performed in patients

  • With known eGFR < 60 ml/min/1.73 m²
  • Who will receive an intra-arterial CM administration
  • Above 70 years of age
  • With a history of renal disease, proteinuria, diabetes mellitus, hypertension, gout, or patients on recent nephrotoxic medication

In patients with acute diseases, their eGFR should be determined within seven days before CM administration; in all others within three months before CM administration.

Most contrast reactions are mild, stressed Fallenberg. Risk factors are high osmolality, ionic types of CM, higher iodine concentrations, and higher injection speed.

Patient Information and Catheter Patency

“You should inform your patient about potential reactions to the contrast administration”, said Fallenberg. Common transient minor reactions are warm flushing and altered sense of tasting.

Before CM administration, the patency of the intravenous catheter should be checked by flushing with 0.9% normal saline, she recommended.

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In the Rare Case – If Something Occurs

In the rare case that something occurs, Fallenberg recommended five immediate assessments of the patient:

  • How does the patient look?
  • Can the patient speak and how does his/her voice sound?
  • How is the patient breathing?
  • What is the patient’s pulse strength and rate?
  • What is the patient’s blood pressure?

These findings will allow to quickly determine the severity and character of a reaction.

Necessary drugs and equipment

Finally, Fallenberg quoted the ESUR Guidelines on which first line emergency drugs and equipment should be in the examination room:

  • Oxygen
  • Adrenaline 1:1000
  • Antihistamine H1 – suitable for injection
  • Atropine
  • Beta2-agonist metered dose inhaler
  • Intravenous fluids – normal saline or Ringer's solution
  • Anti-convulsive drugs (diazepam)
  • Sphygmomanometer
  • One-way mouth 'breather' apparatus

Presentation Title: What you need to know when using contrast media in breast imaging
Speaker: Eva Maria Fallenberg, University Hospital LMU Munich/Germany
Date: February 27 2019
Session code: SY 2b