Management of Contrast Extravasation
When contrast extravasation occurs during a procedure, immediately stop the infusion, leave the cannula in place, aspirate as much extravasated solution as possible through the existing line, apply dry cold compresses for 15-20 minutes four times daily for 24-48 hours, elevate the affected limb, and provide analgesia as needed. 1, 2, 3
Immediate Actions (First 5 Minutes)
Step 1: Stop the infusion immediately upon recognition of extravasation without removing the cannula. 1, 2, 3
Step 2: Aspirate extravasated contrast by gently withdrawing as much solution as possible through the existing cannula before removal, documenting the volume removed in the patient record. 1, 2 This critical step reduces the amount of contrast remaining in tissues and decreases potential tissue damage. 3, 4
Step 3: Avoid applying manual pressure over the extravasated area, as this can worsen tissue damage by forcing contrast deeper into tissue planes. 1, 2
Step 4: Disconnect and remove the IV line only after attempting aspiration. 3
Supportive Care Measures (First 24-48 Hours)
Apply dry cold compresses (ice packs) for 15-20 minutes, four times daily for 24-48 hours to promote vasoconstriction and theoretically limit drug dispersion. 1, 2, 3 Avoid alcohol-based compresses. 1
Elevate the affected limb to reduce edema and improve venous drainage. 1, 2, 3
Administer analgesia as necessary for patient comfort. 1, 2
Clinical Assessment and Monitoring
Assess for signs of compartment syndrome including severe pain disproportionate to clinical findings, paresthesias, pallor, pulselessness, and paralysis. 5, 6 These findings warrant immediate surgical consultation. 5, 6
Monitor for skin and soft tissue compromise including progressive erythema, induration, blistering, or skin breakdown. 5, 6, 3 Most extravasations result in minimal swelling or erythema with no long-term sequelae, particularly with modern non-ionic contrast media. 5, 6
Perform frequent neurovascular checks including pulse and sensation examinations over the first 24-48 hours. 5
When to Obtain Surgical Consultation
Obtain plastic surgery consultation immediately when any of the following are present: 5, 6
- Obvious signs of skin and soft tissue compromise (progressive erythema, blistering, skin necrosis)
- Symptoms or signs of compartment syndrome
- Large volume extravasation (>100-150 mL)
- Persistent severe pain despite conservative management
Consider radiographic assessment with imaging to evaluate for compartmentalization if large volume extravasation or clinical concern for compartment syndrome exists. 4
Important Clinical Context
Non-ionic contrast media (used in 94% of modern CT studies) has greatly reduced the incidence of severe extravasation injuries compared to older high-osmolar ionic agents. 5, 6 In a series of 102 consecutive cases using predominantly non-ionic media, immediate surgical therapy was necessary in zero cases, and conservative management was successful in all patients. 5
Volume matters: Extravasation of less than 100 mL occurred in 90% of cases and was managed conservatively without complications. 5 Large volumes of high-osmolar contrast media are known to induce significant tissue damage and compartment syndrome. 6
High-risk populations include infants, young children, unconscious patients, and debilitated patients who cannot report symptoms early. 6, 3 These patients require particularly vigilant monitoring.
Critical Pitfalls to Avoid
Do NOT use subcutaneous corticosteroids, as retrospective data demonstrates that intralesional corticoids increased the need for surgical debridement (46% vs 13% without corticoids). 1, 2
Do NOT remove the cannula immediately before attempting aspiration of extravasated solution. 1
Do NOT apply manual pressure to the extravasation site. 1, 2
Documentation Requirements
Document the following mandatory elements: 1
- Patient name and identification number
- Date and time of extravasation
- Type and volume of contrast extravasated
- Signs and symptoms (including patient-reported)
- Description of IV access site and location
- Estimated extravasation area and volume
- Management steps taken with times
- Photographic documentation (helpful for follow-up and decision-making)
Inform the patient about the scope of the problem, expected resolution timeline, and when to seek further care. 1
Surgical Management (Rare Cases)
Surgical debridement is reserved for unresolved tissue necrosis or pain lasting more than 10 days. 1 Only approximately one-third of extravasations progress to ulceration. 1
Surgical procedure should consist of wide three-dimensional excision of all involved tissue, temporary coverage with biologic dressing, simultaneous harvesting and storage of split-thickness skin graft, with delayed graft application at 2-3 days once the wound is clean. 1