Cardiac Catheterization Nurses Knowledge of Contrast-Induced Nephropathy: A Quality Improvement Project

Contrast-induced nephropathy (CIN) is the development of acute kidney failure after radiographic contrast media administration. CIN is the third leading cause of hospital acquired kidney failure and is associated with increased risk for morbidity and mortality. Currently no treatment exists for CIN and only supportive care is provided with the anticipation renal function will resolve eventually. Cardiac angiogram or catheterization is one of the most commonly performed procedures with an average of 2 million cases annually. Cardiac catheterizations require large amounts of radiographic contrast media placing patients at risk for the development of CIN. Prevention of CIN is key and requires early identification of risk factors, timely precautions and patient education, which is conducted largely by nursing staff. For this quality improvement project, an informal needs assessment was conducted within the cardiac catherization laboratory at Landmark Medical Center which identified nurse’s had limited knowledge of CIN. All staff nurses in the cardiac catheterization laboratory were invited to participate in an education seminar on CIN. A pretest, educational program, posttest design was used to identify change in nurse’ knowledge of CIN. Nine out of eleven nurses (82%) participated in the educational seminar, completed the pretest and posttest. The posttest scores had a 51-percentage point increase and every posttest question improved in comparison to the pretest. Findings from this quality improvement project suggest that nurses’ ability to recognize CIN risk factors and knowledge of preventative strategies increased significantly after participation in an educational program.

ANALYSIS OF COMPLICATIONS INDUCED BY IODINE-BASED RADIOGRAPHIC CONTRAST MEDIA AND OF METHODS OF THEIR PREVENTION (A literature review)

The existence of modern medical practice is impossible without the use of radiological diagnostic methods. Due to the introduction of evidence-based medicine, most diagnoses need to be confirmed by imaging techniques, and some diseases require radiographic contrast media. Despite the medical and scientific breakthrough in these technologies, there are still risks of developing an individual body reaction to the contrast agent. In view of this, the purpose of the work was to substantiate the choice of iodine-containing radiographic contrast agents, to study the possible complications caused by these substances during the X-ray examination, and the methods of prevention of such conditions. To determine these key points, an analytical review of the literature was conducted. Analysis of iodine-containing radiographic contrast agents, which differ in their chemical structure and properties, showed the advantage of non-ionic radiographic contrast media over the ionized ones. The work considers hypersensitive reactions and thyroid dysfunctions caused by the introduction of iodine-containing contrast agents. The allergic reactions may occur occur regardless of the dose of the drug, immediately or after some time after the examination. Due to the fact that the average duration of radiographic examination is from a few minutes to an hour, the appearance a certain reaction to iodine-containing radiographic contrast agents in a patient may not be established in time. That is why, it important to monitor a patient in the radiology department for 30 minutes after the examination. When establishing an increased risk of hypersensitivity reactions, due to the collection of anamnesis, it is necessary to carry out premedication with glucocorticoids is recommended according to the scheme that is described in the literature and is used in the modern medical practice. The development of hyperthyroidism or hypothyroidism depends on the initial level of hormones and the correct operation of the response system. In the presence of anamnestic and laboratory risk factors that can cause the occurrence of these conditions (TSH, free T4, total T3 and Thyroid peroxidase antibodies), it is recommended to consult an endocrinologist and, based on his/her judgement, to carry out premedication with the control of the TSH levels according to the schemes presented in the literature review or, alternatively, to correct the existing pathological conditions before the examination.

Histological and SEM Assessment of Blood Stasis in Kidney Blood Vessels after Repeated Intra-Arterial Application of Radiographic Contrast Media

Background: After application of iodinated contrast media (CM), a pronounced deterioration of the microcirculation in skin and myocardium was reported. Clinically, the repeated application of CM, especially, led to an increase of the renal resistance index (RRI). With respect to the transiency of the RRI increase, it is reasonable to assume that the deterioration of blood flow could be due to transient blood stasis caused by reversible morphologic cell alterations due to osmotic discrepancies between CM and human blood. Therefore, the hypothesis was investigated whether CM are able to induce in vivo such blood stasis and cell deformations in the renal vasculature of well-hydrated pigs. Methods: The in vivo study was performed as a prospective randomized examination to compare the effects of two different CM in 16 pigs (German Landrace). Pigs were randomized to receive either Iodixanol (n = 8), or Iopromide (n = 8). Each animal received 10 injections separated by 5-min intervals via the suprarenal aorta at a rate of 10 mL/s according to the usual procedure during a cardiac catheter examination. Finally, the kidneys were explanted and processed for histology (H & E staining and fibrin staining according to Weigert) as well as for scanning electron microscopy (SEM) with regards to morphologic correlates explaining the changes in the microcirculation. Results: In each of the predefined four categories of vascular diameters, blood stasis were found, but clearly more often after application of Iopromide than after application of Iodixanol (p < 0.001). In addition, Iopromide induced more blood stasis in all of the examined kidney regions compared to Iodixanol (p = 0.0001). There were no obstructive events in the middle cortex following the application of Iodixanol. Except for the region around a puncture channel of a placed-in catheter probe, no fibrin was detected in Weigert’s fibrin-stained samples, neither around the histologically assessed thrombi nor in vessels with blood stasis. Complementary SEM analyses revealed in a few cases only a slight generation of fibrin and thrombi and deformations, such as echinocyte and “box-like” deformations. Conclusions: According to previous in vitro studies, pathological erythrocyte deformations, such as echinocyte and box-like formation of erythrocytes, were observed also in vivo. In addition, blood stasis and/or thrombi could be detected in histological samples from explanted kidneys from young pigs after repeated in vivo administration of CM. In only a few cases, mural platelet aggregates within minimal fibrin meshes occurred only after the application of Iopromide.

Adverse Drug Reactions to Radiographic Contrast Media in a Teaching Hospital in North India: An Observational Study

Background: Radiocontrast media are used extensively nowadays to visualize internal organs. Currently, non-ionic iodinated contrast media are used which are generally considered to be safe but some adverse reactions have been reported. Thus, the present study was carried out to analyze the nature and incidence of adverse drug reactions (ADRs) to radiographic contrast media in a teaching hospital. Methods:An observational study carried out for a period of six months in a teaching hospital. Contrast media induced adverse reactions were analyzed in terms of affected organs, rate, causality assessment, severity and preventability. The treatment and outcomes of adverse events were also recorded. Naranjo Probability Scale was used to evaluate the relationship between the contrast agent used and the suspected ADR. The severity of the suspected ADRs was determined using Hartwig Scale and preventability was assessed using modified Schumock and Thornton criterion. Results:A total of 15 suspected ADRs occurred in 11 patients with an incidence of 1.4%. It included 5 (45.4%) males and 6 (54.5%) females (p < 05). The highest percentage (72.7 %) of ADRs was seen in adult patients, the mean age being 40.8 years. Vomiting (33.3%) was the most common ADR noted followed by severe nausea and rashes. 64.7 % of ADRs were categorized as probable and 35.3 % were possible. Adverse reactions required treatment in 46.6% patients. There was no fatality reported. Conclusion:The reactions observed were mild to moderate in severity and occurred within 30 minutes of the administration of the contrast.