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Opinion |
1 Department of Radiology, University of Washington, Box 357115, 1959 NE Pacific
St., Seattle, WA 98195.
2 Ogden Murphy Wallace PLLC, Attorneys at Law, Seattle, WA.
Received September 22, 2008;
accepted after revision September 25, 2008.
FOR YOUR INFORMATION
Keywords: adverse effects • contrast media • intrathecal injection
Iodinated contrast media are an integral part of patient care, and methods of reducing risks to the patient from contrast media require constant vigilance. An opportunity to further reduce the risk for some patients and, at the same time, reduce the legal risk of negligence for the radiologist is available to us.
Administering conventional, ionic, high-osmolality contrast media (HOCM) intrathecally is contraindicated and has been for more than two decades. Yet, despite efforts by the American College of Radiology (ACR) through educational programs beginning in the 1980s and the more recent ACR guidelines [1], errors still occur [2-4], and serious neurologic injuries and deaths have occurred in recent years [3, 4].
Why do these serious incidents continue to occur? Technologists, residents, and radiologists make mistakes. How? The following are a few scenarios:
You might be tempted to say, "Impossible! Can't happen!" But it did at different institutions within the same state within the past 2 years [3, 4].
When nonionic, low-osmolality contrast media (LOCM) were first available in the 1980s, they cost from 16 to 20 times more than HOCM. Many radiologists advocated using these new nonionic LOCM for intravascular studies selectively rather than universally for patients at higher risk of an allergic reaction. By the early 1990s, 80% of institutions had switched to using only nonionic LOCM intravascularly [5]. Gradually, as the differential cost dropped to 3:1, more radiology departments changed to using only nonionic LOCM for intravascular use, and we advocated that position in 2005 [6].
However, our department still kept 50- and 100-mL bottles of conventional HOCM for use in nonvascular studies, such as sinography, retrograde pyelography, and other nonvascular catheter injections. But retaining HOCM within the department can create the potential situation in which an incorrect bottle of contrast medium might be used for an intrathecal injection, as noted in the scenarios listed.
The costs of contrast agents have continued to change and for many departments the acquisition costs for nonionic LOCM are now less than for HOCM. What happened? While the cost of nonionic LOCM continued to slowly decrease, the cost of HOCM increased substantially over the past decade. What we have discovered recently in our practice association purchase contracts is that nonionic LOCM are now clearly less expensive than HOCM by a number of dollars per 100 mL. Therefore, we have removed the smaller 50- and 100-mL bottles of HOCM from our department to avoid any confusion.
If such a cost change has occurred in your department, why even have HOCM in these smaller-sized bottles? Why allow a potential situation to exist in which a mistake might be made?
We propose the following recommendations. First, review carefully what you now pay for your HOCM and your LOCM contrast agents. Second, if the cost of LOCM is similar or less than that of HOCM, eliminate the standard 50- and 100-mL bottles of HOCM from your department. Instead, use LOCM for those procedures for which you previously used HOCM. Third, if you find that the cost differential is still significantly in favor of having some HOCM in your department for selected nonvascular studies, establish a strict, regular educational program for technologists and radiologists and take special precautions to ensure that HOCM cannot be selected erroneously for a myelogram. If such a preventive program seems too onerous, consider absorbing any cost differential and eliminate HOCM from your department. It might well be cost-saving in the long run.
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