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B. : , .. Gadobenate dimeglumine (MultiHance), Gadofosveset trisodium (Vasovist), gadoxetate disodium (Primovist) . 5 e- 3 1 Gd Mangafodipir trisodium (Teslascan): 2- Manganese chloride CMC-001 (LumenHance): 1.

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CTA DSA CO2 Kyung J Cho, Irvin F Hawkins Carbon Dioxide Angiography e-medicine 21 Oct 2008

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**Eur Radiol (2004) 14:476481 Management of acute adverse reactions to contrast media, ,

*Any patient who describes an allergy to a food or contrast media should be questioned further to clarify the type and severity of the allergy or reaction, as these patients could be atopic and at increased risk for reactions ** prednisolone : PresolonMethylprednisolone: MedrolCorticosteroids should be used with caution in patients with uncontrolled hypertension, diabetes [24], tuberculosis, systemic fungal infections, peptic ulcer disease or diverticulitis1.Prednisone 50 mg by mouth at 13 hours, 7 hours, and 1 hour before contrast media injection, plusDiphenhydramine (Benadryl) 50 mg intravenously, intramuscularly, or by mouth 1 hour beforecontrast medium [12].or2. Methylprednisolone (Medrol) 32 mg by mouth 12 hours and 2 hours before contrast media injection. An anti-histamine (as in option 1) can also be added to this regimen injection [34].If the patient is unable to take oral medication, 200 mg of hydrocortisone intravenously may be substituted for oral prednisone in the Greenberger protocol [35].1. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg or hydrocortisone sodium succinate (Solu-Cortef) 200 mg intravenously every 4 hours (q4h) until contrast study required plus diphenhydramine 50 mg IV 1 hour prior to contrast injection [35].2. Dexamethasone sodium sulfate (Decadron) 7.5 mg or betamethasone 6.0 mg intravenously q4h until contrast study must be done in patent with known allergy to methylpred-nisolone, aspirin, or non-steroidal anti-inflammatory drugs, especially if asthmatic. Also diphenhydramine 50 mg IV 1 hour prior to contrast injection.3.Omit steroids entirely and give diphenhydramine 50 mg IV.Note: IV steroids have not been shown to be effective when administered less than 4 to 6 hours prior to contrast injection.*** . . *ACR manual 20124 Paraproteinemias, particularly multiple myeloma, are known to predispose patients to irreversible renal failure after high-osmolality contrast media (HOCM) administration due to tubular protein precipitation and aggregation; however, there is no data predicting risk with the use of low-osmolality or iso-osmolality agents.5 Age, apart from the general health of the patient, is not a major consideration in patient preparation [1]. In infants and neonates, contrast volume is an important consideration because of the low blood volume of the patient and the hypertonicity (and potentially detrimental cardiac effects) of even nonionic monomeric contrast media. Gender is not considered a major risk factor for IV contrast injection.

******- / **Characteristic skin changes seen in a patient with NSF showing hyperpigmentation, skin thickening, and joint flexion contractures. Photographs courtesy of Jonathan Kay, M.D. *Markedly reduced renal function is the most important patient-related risk factor for NSF and has been present in almost all reported cases of NSF, and many patients have been on haemodialysis or peritoneal dialysis.NSF of 18% following exposure to gadodiamide in patients with severe chronic kidney disease (CKD5, GFR less than 15 ml/min/1.73 m2) [37] compared with the incidence of 37% in other series [9]

**No proven unconfounded NSF cases fulfilling the Yale criteria have been linked with any of the gadolinium-based contrast media other than gadodiamide, gadoversetamide and gadopentetate dimeglumine.

**It has also been reported that NSF has occurred after gadobutrol in a few patients who had not received another agent [41]

** that three consecutive haemodialysis treatments over a 6-day period would be needed to remove 97% of the administered extracellular gadolinium-based contrast agent [57].*****The high difference in acoustic impedance between the gas in the microbubble and the surrounding tissue in vivo makes microbubbles highly reflective resulting in the enhanced acoustic backscattering from blood by up to 27 dB in both colour and spectral Doppler modes**EFSUMB Study Group.Guidelines for the use of Contrast Agents in Ultrasound. Ultraschall in der Medizin 2004;25;249-256/Eur J Ultrasound 2004(4)Hohmann J., Albrecht T. et al., Liver metastases in cancer: detection with contrast enhanced ultrasonography. Abdom Imaging (2004) 29:669681Bouakaz A., De Jong N., WFUMB safety symposium on echo-contrast agents: Nature and types of ultrasound contrast agents. Ultrasound in Med. & Biol., Vol. 33, No. 2, pp. 187196, 2007

***Scheme of a SonoVue microbubble with the peripheral phospholipids monolayer fi lled by sulphur hexafl uoride (SF6) gas. (Image courtesy of Peter JA Frinking, PhD, Bracco Research, Geneva, Switzerland)Two-dimensional microscopic photo of SonoVue (white arrows) microbubbles (20 magnifi cation; Optical microscope) compared to red blood cells (black arrows).

***********These acoustically driven bubble oscillations can result in localized heat production, microstreaming of fluid near the bubble, and localized shear stressesInertial collapse of a gas bubble can result in the production of localized high temperatures and pressures, as well as the generation of acoustic shock waves and free radicals.presence of microbubbles in the blood can increase the likelihood of occurrence of some US bioeffects, such as hemolysis, capillary rupture, effects on cardiac rhythm, and localized delivery of drugs or genetic material.************This carbon dioxide digital subtraction angiogram shows patency of the external iliac and transplanted renal arteries. Carbon Dioxide Angiography medscape 2008

**When CO2is injected intothe blood, it is combined with water to produce carbonic acid. It becomes bicarbonate (HCO3 -) in the blood stream;bicarbonatereverts to CO2 before being expelled out of capillaries into the lung.Carbonic anhydrasecatalyzes the conversion of CO2 to bicarbonateand protons. CO2 is eliminated by the lungs in a single pass. However, CO2 bubbles thatwere injected into the venous system may enter the systemic circulation via the patent foramen ovale or intracardiac septal defects.**When CO2is injected intothe blood, it is combined with water to produce carbonic acid. It becomes bicarbonate (HCO3 -) in the blood stream;bicarbonatereverts to CO2 before being expelled out of capillaries into the lung.Carbonic anhydrasecatalyzes the conversion of CO2 to bicarbonateand protons. CO2 is eliminated by the lungs in a single pass. However, CO2 bubbles thatwere injected into the venous system may enter the systemic circulation via the patent foramen ovale or intracardiac septal defects. CO2 is a colorless and odorless gas, and it cannot be visually distinguished from air. The incorrect application of technique may result in air contamination, whichmaycause serious complications. A thorough understanding of the unique physical properties of CO2 is necessary for the safe and effective performance of CO2 angiography.CO2 is approximately 20 times more soluble than oxygen. When injected into a vessel, CO2 bubbles completely dissolve within 2-3 minutes; however, if the gas is trapped in a large abdominal aneurysm, it may persist, allowing gas exchange between the CO2 and nitrogen in the blood. This exchange may result in colonic ischemia,as a result ofocclusion of the inferior mesenteric artery. Two to3 minutes should elapse between injections of CO2 to prevent the localized accumulation of gas bubbles, which may produce a significant gas embolism, particularly in the pulmonary artery.CO2 is compressible during injection;it expands in the vessel as it exits the catheter. Clearing the fluid of the catheter by using 3-5 cc of CO2 before injection reduces the explosive delivery. The explosive delivery is unlikely to cause vascular damage, but it may contribute to discomfort during the injection. The low viscosity and compressibility of the gas accounts for the greater sensitivity of CO2 as a contrast agent in detecting the source of bleeding (gastrointestinal tract and traumatic bleeding), ascompared with iodinated contrast material.CO2 is lighter than blood plasma; therefore, it floats above the blood. When injected into a large vessel such as the aorta or inferior vena cava, CO2 bubbles flow along the anterior part of the vessel, with incomplete blood displacement along the posterior portion. Because of their anterior point of origin, the celiac and superior mesenteric arteries fill well with small volumes (