Biến chứng liên quan đến thuốc cản quang Từ suy thận đến phản vệ

TS.BS. Nguyễn Quốc Thái

VIỆN TIM MẠCH VIỆT NAM

Phân loại thuốc cản quang

1. Thuốc cản quang tia X (Radiographic

Contrast Media)

2. Thuốc đối quang từ (MR Contrast Media)

3. Thuốc cản âm (Ultrasound Contrast

Media)

Phân loại thuốc cản quang tia X

Thuốc cản quang

Negative (Khí, O2, CO2)

Positive

Iodine compound Barium GIT

Water soluble Powder Oily

Thuốc cản quang Iodine

1. Ionic monomeric contrast media (highosmolar contrast media, HOCM), e.g. amidotrizoate, iothalamate, ioxithalamate 2. Ionic dimeric contrast media (low-osmolar contrast media, LOCM), e.g. ioxaglate 3. Nonionic monomeric contrast media (low osmolar contrast media, LOCM), e.g. iohexol, iopentol, ioxitol, iomeprol, ioversol, iopromide, iobitridol, iopamidol 4. Nonionic dimeric contrast media (iso-osmolar contrast media, IOCM), e.g. iotrolan, iodixanol

Contrast Media:

Safety issues and ESUR Guidelines 3rd ed.February 2014.

Biến chứng không liên quan đến thận

Contrast Media:

Safety issues and ESUR Guidelines 3rd ed.February 2014.

Xử trí các biến chứng cấp tính

Nổi mày đay 1. Ngừng tiêm thuốc

2. Không cần điều trị trong phần lớn trường hợp.

3. Cho kháng Histamin H1: uống, tiêm bắp. Nếu triệu chứng nặng và lan rộng cho thuốc đồng vận alpha (co động và tĩnh mạch): epinephrin 0.1-0.3 mg tiêm dưới da.

Phù mặt và thanh quản 1. Give O2 6–10 liters/min (via mask). 2. Give alpha agonist (arteriolar and venous constriction): epinephrine SC or IM (1:1,000) 0.1–0.3 ml (= 0.1–0.3 mg) or, especially if hypotension evident, epinephrine (1:10,000) slowly IV –3 ml (= 0.1–0.3 mg). Repeat as needed up to a maximum of 1 mg. If not responsive to therapy or if there is obvious acute laryngeal edema, seek appropriate assistance (e.g., cardiopulmonary arrest response team).

Tụt HA và nhịp tim nhanh 1. Legs elevated 60 degree or more (preferred). 2. Monitor: electrocardiogram, pulse oximeter, blood pressure. 3. Give O2 6–10 liters/min (via mask). 4. Rapid intravenous administration of large volumes of Ringer’s lactate or normal saline. If poorly responsive: epinephrine (1:10,000) slowly IV 1 ml (= 0.1 mg) Repeat as needed up to a maximum of 1 mg.If still poorly responsive seek appropriate assistance (e.g., cardiopulmonary arrest response team)

Nhịp chậm tụt HA (Vagal Reaction) 1 Secure airway: give O2 6–10 liters/min (via mask) 2. Monitor vital signs. 3. Elevate legs. 4. Secure IV access: rapid administration of Ringer’s lactate or normal saline. 5. Give atropine 0.6–1 mg IV slowly if patient does not respond quickly to steps 2–4. Repeat atropine up to a total dose of 0.04 mg/kg (2–3 mg) in adult. 6. Ensure complete resolution of hypotension and bradycardia prior to discharge.

THA nặng 1. Give O2 6–10 liters/min (via mask). 2. Monitor electrocardiogram, pulse oximeter, blood pressure. 3. Give nitroglycerine 0.4-mg tablet, sublingual (may repeat × 3); or, topical 2% ointment, apply 1-inch strip. 4. If no response, consider labetalol 20 mg IV, then 20 to 80 mg IV every 10 minutes up to 300 mg. Transfer to intensive care unit or emergency department.

CO GIẬT 1. Give O2 6–10 liters/min (via mask). 2. Consider diazepam (Valium®) 5 mg IV (or more, as appropriate) or midazolam (Versed®) 0.5 to 1 mg IV. 3. If longer effect needed, obtain consultation; consider phenytoin (Dilantin®) infusion — 15–18 mg/kg at 50 mg/min. 4. Careful monitoring of vital signs required, particularly of pO2because of risk to respiratory depression with benzodiazepine administration.

Phác đồ xử trí sốc phản vệ

1. Gọi cho đội cấp cứu 2. Đảm bảo đường thở 3. Nâng chân bệnh nhân nếu tụt áp 4. Thở oxy qua mask (6-10l/ph). 5. Adrenaline TB (1:1000): 0.5ml(0.5mg) ở người lớn, nhắc lại khi

cần thiết. Trẻ 6-12 tuổi: TB 0.3ml (0.3mg) Trẻ< 6 tuổi: TB 0.15ml (0.15mg) 5. Truyền TM NaCl sinh lý, Ringer lactat. 6. Kháng Histamin H1 TM.

Contrast Media:

Safety issues and ESUR Guidelines 3rd ed.February 2014.

Các thuốc và phương tiện cấp cứu cần thiết khi tiến hành dùng thuốc cản quang

• Oxygen • Adrenaline 1:1000 • Antihistamine H1 • Atropine • B2 agonist (Ventolin, Bricanyl): thuốc xịt họng, khí dung • Nước muối đẳng trương, Ringer Lactat • Thuốc chống co giật (diazepam) • Monitor theo dõi HA, NT • Dụng cụ đè lưỡi, NKQ.

Biến chứng muộn

• DEFINITION: A late adverse reaction to intravascular iodine-based contrast medium is defined as a reaction which occurs 1 h to 1 week after contrast medium injection.

• REACTIONS:

– Skin reactions similar in type to other drug induced eruptions. Maculopapular rashes, erythema, swelling and pruritus are most common. Most skin reactions are mild to moderate and self-limiting.

– A variety of late symptoms (e.g., nausea, vomiting, headache, musculoskeletal pains, fever) have been described following contrast medium, but many are not related to contrast medium.

RISK FACTORS FOR SKIN REACTIONS: •Previous late contrast medium reaction. •Interleukin-2 treatment. •Use of nonionic dimers. MANAGEMENT: Symptomatic and similar to the management of other drug-induced skin reactions e.g. antihistamines, topical steroids and emollients. RECOMMENDATIONS: •Patients who have had a previous contrast medium reaction, or who are on interleukin-2 treatment should be advised that a late skin reaction is possible and that they should contact a doctor if they have a problem. •Patch and delayed reading intradermal tests may be useful to confirm a late skin reaction to contrast medium and to study cross- reactivity patterns with other agents. •To reduce the risk of repeat reaction, use another contrast agent than the agent precipitating the first reaction. Avoid agents which have shown cross-reactivity on skin testing.

Biến chứng muộn

Phản ứng rất muộn

Definition: An adverse reaction which usually occurs more than 1 week after contrast medium injection.

Type of reaction

• IODINE-BASED CONTRAST MEDIA

Thyrotoxicosis

• GADOLINIUM-BASED CONTRAST MEDIA

Nephrogenic systemic fibrosis

BIẾN CHỨNG THẬN (Renal Adverse Reactions)

Biến chứng thận

• Definition: Contrast induced nephropathy (CIN) is a condition in which a decrease in renal function occurs within 3 days of the intravascular administration of a CM in the absence of an alternative aetiology. An increase in serum creatinine by more than 25% or 44 μmol/l (0.5 mg/dl) indicates CIN.

Biến chứng thận do dùng thuốc can quang Iodine

PATIENT-RELATED • eGFR less than 60 ml/min/1.73 m2 before intra-arterial administration • eGFR less than 45 ml/min/1.73 m2 before intravenous administration • In particular in combination with • Diabetic nephropathy • Dehydration • Congestive heart failure (NYHA grade 3-4) and low LVEF • Recent myocardial infarction (< 24 h) • Intra-aortic balloon pump • Peri-procedural hypotension • Low haematocrit level • Age over 70 • Concurrent administration of nephrotoxic drugs • Known or suspected acute renal failure

PROCEDURE-RELATED

• Intra-arterial administration of contrast medium

• High osmolality agents

• Large doses of contrast medium

• Multiple contrast medium administrations within a few days

Biến chứng thận do dùng thuốc can quang Iodine

Elective Examination

• Consider an alternative imaging method not using iodine-based contrast media.

• Discuss the need to stop nephrotoxic drugs with the referring physician.

• Start volume expansion. A suitable protocol is intravenous normal saline, 1.0-1.5 ml/kg/h, for at least 6 h before and after contrast medium. An alternative protocol is intravenous sodium bicarbonate (154 mEq/l in dextrose 5% water), 3 ml/kg/h for 1 h before contrast medium and 1 ml/kg/h for 6 h after contrast medium.

Xử trí biến chứng thận do dùng thuốc can quang Iodine

Time of examination

• AT RISK PATIENTS – Use low or iso-osmolar contrast media.

– Use the lowest dose of contrast medium consistent with a diagnostic result.

• PATIENTS NOT AT INCREASED RISK Use the lowest dose of contrast medium consistent with a diagnostic result.

Phòng ngừa biến chứng thận do dùng thuốc can quang Iodine

Examinations • The risk of nephrotoxicity is very low when gadolinium-

based contrast media are used in approved doses. RADIOGRAPHIC EXAMINATIONS • Gadolinium-based contrast media should not be used

for radiographic examinations in patients with renal impairment.

• Gadolinium-based contrast media are more nephrotoxic than iodine-based contrast media in equivalent X-ray attenuating doses.

Biến chứng thận do dùng thuốc đối quang từ Gadolinium

KẾT LUẬN

• Biến chứng liên quan đến thuốc cản quang trên lâm sàng: tuy ít gặp nhưng đa dạng.

• Chuẩn bị đầy đủ các thuốc và phương tiện cấp cứu cần thiết khi thực hiện các phương pháp chẩn đoán cũng như thủ thuật có dùng thuốc cản quang.