Biến chứng liên quan đến thuốc cản quang: Từ suy thận đến phản vệ - Nguyễn Quốc Thái

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.