The Benefits of Saline and Dual-Head Injectors

 Applied Radiology Editorial Team 

The use of single-head injectors in CT imaging has shifted significantly to dual-head and syringeless injectors. The advantages of dual-head and syringeless systems are that they permit loading of contrast and saline onto the same injector. Newer contrast-injection systems integrate enhancements to manage injector protocol data, improve patient safety, and workflow efficiency.

Among the available CT dual-head injectors in the United States, several include Bracco Diagnostics’ EmpowerCTA®+, Bayer’s Medrad® Stellant, Guerbet’s OptiVantage®, and GE’s CT Motion™. The most recent technologies, known as Smart CT injectors, are capable of capturing injection protocol data for every CT study and delivering it to Voice Dictation, RIS, PACS, and EMR systems for standardized documentation. Concurrently, radiation dose can be collected, recorded, and made available for each exam.

Ryan Lee, MD, Section Chief of Neuroradiology and Vice Chair of Safety and Quality at the Einstein Healthcare Network, gave his perspective on data collection during a recent expert panel meeting. “I think where we want to go is tailor the protocols to the specific patient,” Dr. Lee said. “If we can pull information from any source that we have and figure out what the correct protocol should be, including the correct radiation dose, I think we can do the same thing for contrast dose.”

“I think as we get more and more Big Data we can use the power of informatics and machine learning and move towards the direction of tailoring protocols for specific patients,” he added.

The Bracco SmartInject Technology, powered by NEXO® Contrast Management System, offers a centralized server-based system for standardized contrast delivery management supporting compliance, tracking real-time performance, streamlining clinical workflow and increasing productivity by monitoring and managing patient safety while keeping up-to-date patient records by synchronizing and seamlessly connecting them with RIS/ PACS, EMR, and voice dictation.

Besides offering multiple patient safety measures, smart dual-head injectors can incorporate a saline flush, which ensures complete delivery of the contrast dose into the circulatory system and can reduce the amount of iodine needed to achieve optimal imaging. They also can offer such benefits as better bolus geometry, fewer artifacts on some CT studies, and reduced risk for contrast-induced nephropathy.1

A dual-head injection protocol consists of an initial saline test injection administered manually to confirm patency of venous access, followed by power injection of contrast bolus and a saline chaser.

Expert panel members Daniele Marin, MD, Medical Director, Duke University School of Medicine and Emilio Vega, Manager, CT Quality and Safety, NYU Langone Health, discuss the benefits of saline utilization. Click here to view the video.

Since contrasted CT studies require contrast administration at high-flow, high-volume fixed rates, they are associated with relatively high pressure that can increases extravasation risk.2,3 Extravasation typically occurs during intravenous (IV) administration, when the IV cannula dislodges and punctures the vessel wall, causing leakage into extravascular tissue.4 While most extravasation cases cause minimal inflammation and erythema, further complications such as skin ulceration, tissue necrosis, and compartment syndrome, can occur.5

According to American College of Radiology (ACR) estimates, of the 36 million contrast-enhanced CT (CECT) exams performed annually in the United States, extravasations occur in 0.1% to 1.2%, or about 36,000 to 430,000 procedures, per year.5,6 In this context, prevention strategies and best practices to identify at-risk patients are important; the Einstein Healthcare Network modified its practices to leverage saline to help reduce the number of extravasations. During monthly quality improvement meetings, Dr. Lee said, he and his colleagues reported lower extravasation rates for cardiac CT angiography (CCTA) exams compared to other CT exams.

“We wondered what we were doing differently in CCTA exams,” he said, noting that the difference lay in the performance methodology of saline test injections. Manual hand test injections were performed in all CECT studies except for CCTA examinations, which utilized power test injections. The group began experimenting with saline test injections using the power injector in all CECT studies. Their rationale: power injecting saline mimics the pressures of contrast injection more closely than hand injection. As such, the method has a better chance of identifying a weak IV line. Extravasation of saline during a test injection is less risky than contrast extravasation, which can have toxic side effects.

“Additional benefits of using a power-injected test bolus of saline is the standardization effect. By routinely using power injection for the test bolus, the test injections were consistent using the same flow rate each time as opposed to hand injections, which vary from technologist to technologist,” Dr. Lee said, noting the new test injection protocol has proven to reduce the facility’s extravasation rate by over 50%.

Hear Dr. Lee describe the Einstein department’s experience.

“There are more costs associated with a dual-head injector,” Dr. Lee said. “The argument I presented was, ‘if this works, we’re going to be saving costs on the backend for not having to deal with as many extravasations.’” The saline test injection protocol has since been adopted across the network; emergency, in-patient, and outpatient sites all employ a saline test injection using the power injector prior to contrast administration. 

Dr. Lee believes the saline test injection protocol can be generalized to other institutions to reduce variability and risk while helping clinicians achieve the best possible images. The expert panel agreed that leveraging the use of saline with the dual-head injectors leads to more efficient workflows and better patient care.

 

The Saline Advance feature of the EmpowerCTA®+ Injector System allows technologists to test venous patency and integrity prior to contrast injection by delivering saline test bolus at the same flow rate as the contrast media protocol.

References:
  1. Bae KT. Intravenous contrast medium administration and scan timing at CT: considerations and approaches. Radiology. 2010; 256:32-61.
  2. Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR. Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69 657 intravenous injections. Radiology. 2007; 243:80-87. 
  3. Behzadi AH, Farooq Z, Newhouse JH, Prince MR. MRI and CT contrast media extravasation: a systematic review. Medicine (Baltimore). 2018;97:e0055. 
  4. Conner B, Ash R, Allen W, et al. Preventing intravenous contrast extravasation in CT: a simple solution. J Am Coll Radiol. 2017;14:1326-1332. 
  5. ACR Manual on Contrast Media. 2023. Available at: https://www.acr.org/Clinical-Resources/Contrast-Manual. Accessed May 9, 2024.
  6. Zagoudis J. Decreasing CT Contrast Extravasation. Available at: https://www.itnonline.com/article/decreasing-ct-contrast-extravasation. Accessed June 14, 2021. 
The views, information, or opinions expressed in the video(s) or article(s) above are solely those of the individuals involved and do not necessarily represent those of Bracco Diagnostics Inc. (“BDI”). The primary purpose of this video(s) or article(s) is to educate and inform. This information does not constitute medical or other professional advice or services.

IMPORTANT SAFETY INFORMATION  |  INDICATIONS AND USAGE

EmpowerCTA®+ Injector System

Caution: Federal law restricts this device to sale by or on the order of a physician.

INDICATIONS:

The EmpowerCTA®+ Injector System is indicated for the vascular administration of contrast and flushing media in conjunction with computed tomography (CT) scanning of the body with an optional interface to a CT scanner and an optional calculator for glomerular filtration rate (GFR).

EmpowerCTA®+ Injector System

Caution: Federal law restricts this device to sale by or on the order of a physician.

INDICATIONS:

The EmpowerCTA®+ Injector System is indicated for the vascular administration of contrast and flushing media in conjunction with computed tomography (CT) scanning of the body with an optional interface to a CT scanner and an optional calculator for glomerular filtration rate (GFR).

Protocols have been independently developed and are not intended as medical advice. Bracco and Bracco Injeneering S.A. shall not be responsible for any physicians’ reliance on these or any other products.

CONTRAINDICATIONS:

The EmpowerCTA®+ Injector System is not intended for use as a long-term infusion pump, nor is it intended to be used to inject any agents other than contrast or flushing media. Do not attempt to use the injector for any other purpose (such as chemotherapy or drug infusion). The EmpowerCTA+ Injector System should not be used to inject substances into nonvascular body cavities. Any applications of the EmpowerCTA+ Injector System other than those described in its Operator Manual are inappropriate and should not be attempted.

Not all products are available in all global markets.

EmpowerCTA+ is distributed by Bracco Diagnostics Inc.; 259 Prospect Plains Road, Bldg. H; Monroe Township, NJ 08831 USA; Phone: (800) 631-5245; Fax: (609) 514-2424; Customer Service: 1-877-BRACCO 9 (1-877-272-2269); Scientific Information: 1-800-257-5181 (Option 2); EmpowerCTA+ Email: empowerinfo@diag.bracco.com; Website: https://smartinject.wpenginepowered.com/ct-solutions/

EmpowerCTA+ is manufactured by Bracco Injeneering S.A., Avenue de Sevelin 46, CH – 1004 Lausanne, Switzerland. https://www.bracco.com/

 

EmpowerMR® Injector System

Caution: Federal law restricts this device to sale by or on the order of a physician.

INDICATIONS:

The EmpowerMR® Injector System is indicated for vascular administration of contrast media and flushing media in conjunction with magnetic resonance imaging (MRI).

Protocols have been independently developed and are not intended as medical advice, and Bracco shall not be responsible for any physicians' reliance on these or any other protocols.

Bracco Injeneering S.A. reserves the right at any time and without notice, to change the specifications and features described herein, or to change the production or adjust the product described.

Not all products are available in all global markets.

EmpowerMR is distributed by Bracco Diagnostics Inc.; 259 Prospect Plains Road, Bldg. H; Monroe Township, NJ 08831 USA; Phone: (800) 631-5245; Fax: (609) 514-2424; Customer Service: 1-877-BRACCO 9 (1-877-272-2269); Scientific Information: 1-800-257-5181 (Option 2); Website: https://smartinject.wpenginepowered.com/mr-solutions/

EmpowerMR is manufactured for Bracco Injeneering S.A., Avenue de Sevelin 46 CH – 1004 Lausanne, Switzerland. https://www.bracco.com/

 

NEXO® Contrast Management System

Intended Use:

The NEXO® Contrast Management System is a server-based application intended to be used as a data management and visualization system. The NEXO Contrast Management System can read, store, share, compare/relate, as well as graphically display data and injection programs coming from RIS, PACS, and multiple enabled EmpowerCTA® Injector Systems. This device provides users with record lists, graphics, and reports about data and performances.

This device is intended for retrospective and statistical data management and visualization. It is not intended for real-time data visualization, diagnostic applications, or for any other use for which the device is not indicated. This device is only to be operated by and under quasi-continuous supervision of qualified and trained staff in an appropriately licensed healthcare facility.

The NEXO Contrast Management System is compatible with the EmpowerCTA Injector System version 8.0, and EmpowerCTA®+ Injector System version 10.0 and higher.

Not all products are available in all global markets.

NEXO is distributed by Bracco Diagnostics Inc.; 259 Prospect Plains Road, Building H; Monroe Township, NJ 08831 USA; Phone: (800) 631-5245; Fax: (609) 514-2424; NEXO Customer Service: 1-877-BRACCO 9 (1-877-272-2269); NEXO questions: Nexo.Answers@diag.bracco.com; NEXO U.S. Technical Service and Support: Phone: 888-670-7701; Fax: 609-514-2448; NEXO Email: customer.support@acistmedical.com; Website: https://smartinject.wpenginepowered.com/digital-solutions

NEXO is manufactured by ACIST Medical Systems, 7905 Full Road, Eden Prairie, MN 55344 USA.

 

About Bracco Injeneering S.A.

Bracco Injeneering S.A., located in Lausanne, Switzerland, is the most recently added Business Unit of Bracco Imaging. Bracco Injeneering is committed to developing the best-in-class, integrated injection solutions with a strong heritage in research and innovation. It provides quality solutions for state-of-the-art radiology centers, offering proven injection technology, built on Bracco Imaging’s expertise.

Thanks to this strengthened product portfolio, including the EmpowerCTA®+ Injector System and EmpowerMR Injector System Bracco Imaging will be able to focus on constant innovation, not only for devices but also for software development and data management.

EmpowerCTA, EmpowerMR, NEXO, and IRiSMR are registered trademarks of Bracco Injeneering S.A., registered in the U.S.

FastLoad is a trademark of Bracco Injeneering S.A.

All other trademarks and registered trademarks are the property of their respective owners.