DB13T 1283.4-2010醫(yī)學(xué)影像學(xué)診療技術(shù)標(biāo)準(zhǔn) 第4部分 醫(yī)學(xué)影像學(xué)對(duì)比劑應(yīng)用指南

ICS040河北省地DB13方標(biāo)準(zhǔn)DB13/T1283.4—2010醫(yī)學(xué)影像學(xué)診療技術(shù)標(biāo)準(zhǔn)Technicalstandardfordiagnosesandtherapyofmedicalimaging--part4:guidelinesoncontrastmediainmedicalimaging河北省質(zhì)量技術(shù)監(jiān)督局發(fā)布IDB1283.4—2010 比劑 1 陰性對(duì)比劑 1 1 12.1.3二氧化碳、氮?dú)?1 2 2化特性 2 3 3 4血管系統(tǒng)的影響 5功能的影響 5系統(tǒng)的影響 5系統(tǒng)的影響 5的影響 5 5險(xiǎn)因素 6 DB1283.4—2010 劑過敏反應(yīng)的受累器官及臨床表現(xiàn) 7驗(yàn) 7 8 的監(jiān)測 10的觀察 10 處理 11 13 13 DB1283.4—2010前言第DB1283.4—20101DB1283.4—2010作者。學(xué)對(duì)比劑定義resonanceimaging，MRI)和超聲醫(yī)學(xué)中也叫增強(qiáng)劑(enhancer)。對(duì)比劑是可以通過某種特定的途徑引影像學(xué)的重要信息。分類劑使對(duì)比區(qū)的器官或組織的密度/信號(hào)減低或增高而分成陰性對(duì)比劑和陽性對(duì)比陰性對(duì)比劑2.1.1空氣氧氣后反應(yīng)少。。二氧化碳、氮?dú)?DB1283.4—2010。陽性對(duì)比劑1鋇劑含碘對(duì)比劑碘原子序數(shù)較高，能有效地吸收X射線，為人體最常使用的對(duì)比劑，特別是在心臟、大血管、泌入人體的技術(shù)方法a)直接引入方法：法：如胃腸道雙重對(duì)比造影；灌注方法：如鋇氣雙重對(duì)比灌腸造影、支氣管造影和子宮輸卵管造影；3)穿刺注入方法：如關(guān)節(jié)腔造影、椎管造影、血管造影與介入性放射學(xué)治療。b)間接引入方法：：如靜脈尿路造影、口服膽囊造影；生理吸收方法：如間接淋巴管造影；3)生理聚集方法：如淋巴結(jié)造影。對(duì)比劑的理化特性性對(duì)比劑的理化特性:—容易合成;—在體內(nèi)、體外均呈高度穩(wěn)定;—完全溶于水;—溶液滲透壓低;——非離子型二聚體對(duì)比劑3DB1283.4—2010離子型對(duì)比劑苯環(huán)上1位側(cè)鏈為羧基鹽(－COOR)，具有此結(jié)構(gòu)的碘對(duì)比劑水溶性高，在水溶液中可解離成陰離子(含三碘苯環(huán))及陽離子(葡甲胺、鈉、鈣、鎂)。非離子型對(duì)比劑苯環(huán)上1位側(cè)鏈為酰胺衍生物(－CONH)，其水溶性很高，但在水中不解離。單體對(duì)比劑指一分子對(duì)比劑僅有一個(gè)三醫(yī)用硫酸鋇混懸劑硫酸鋇用于胃腸道X線造影，醫(yī)用純凈硫酸鋇為白色顆粒，無味，微溶解于酸和堿，耐熱，附著系用碘對(duì)比劑1)可由胃腸道吸收。2)在膽道以足夠的濃度排出。3)低毒性，不良反應(yīng)少。等。磁共振所用的對(duì)比劑，其本身不產(chǎn)生信號(hào)，其信號(hào)對(duì)比來自氫原子核(即質(zhì)子)，磁共振對(duì)比劑可縮短某些質(zhì)子的弛豫時(shí)間，從而間接地改變這些質(zhì)子所產(chǎn)生信號(hào)的強(qiáng)度?？煞譃橄铝袃煞N：以縮短T1弛豫時(shí)間為主(使磁共振信號(hào)增強(qiáng))或以縮短T2弛豫時(shí)間為主(使磁共振信號(hào)下降)。還可使用一些無在重T1加權(quán)圖像上可為陽性增強(qiáng)，后者常用于磁共振血管造影。MRI對(duì)比劑使組織質(zhì)子弛豫增強(qiáng)的能力稱為弛豫效率，為對(duì)比劑濃度和弛豫4DB1283.4—2010不良反應(yīng)因素有關(guān)，發(fā)生機(jī)制相當(dāng)復(fù)雜。水溶性尿路排泄X線碘對(duì)比劑為臨床上用量最大、不同程度的不良反。般性反應(yīng)性反應(yīng)－化學(xué)反應(yīng)大汗、尿失禁、對(duì)比劑對(duì)神經(jīng)系統(tǒng)的影響或昏迷。梗死的可能，需要對(duì)癥處理。5DB1283.4—2010對(duì)比劑對(duì)心血管系統(tǒng)的影響較大。對(duì)比劑對(duì)腎臟功能的影響前提下，使用對(duì)比劑后3天之內(nèi)發(fā)生的急性腎功能損害(血肌酐超過之前的25％或44μmol/l(0.5mg/dl))。對(duì)比劑腎病多表現(xiàn)為非少尿型急性腎功能衰竭，多數(shù)患者腎功能可于7~10天恢復(fù)。部分患對(duì)比劑對(duì)血液系統(tǒng)的影響劑的不良反應(yīng)。對(duì)比劑對(duì)消化系統(tǒng)的影響性對(duì)比劑對(duì)甲狀腺的影響對(duì)比劑對(duì)肺部的影響6DB1283.4—2010劑不良反應(yīng)發(fā)生的危險(xiǎn)因素a部位的碘對(duì)比劑造影和介入治療其不良反應(yīng)發(fā)生的幾率較高，應(yīng)加以注意：、左心室造影、肺動(dòng)脈造影、脊髓動(dòng)脈造影等；2)高濃度、快速碘對(duì)比劑注入和劑量大的造影或介入操作。b)有對(duì)比劑過敏史或其他藥物過敏史者發(fā)生不良反應(yīng)的危險(xiǎn)性均高于普通人。c)肝腎功能損害者尤其是中度及重度腎功能障礙病人，造影后引起腎功能障礙的加重。d)糖尿病、骨髓瘤、甲狀腺功能亢進(jìn)、禁水和脫水狀態(tài)的病人碘對(duì)比劑不良反應(yīng)發(fā)生率大。f)哮喘、蕁麻疹、濕疹及其他過敏性疾病碘對(duì)比劑反應(yīng)的發(fā)生率高。g)某些少見的特殊病例，如鐮狀細(xì)胞貧血、嗜鉻細(xì)胞瘤等對(duì)碘對(duì)比劑不良反應(yīng)發(fā)生率高。h)嬰幼兒、60歲以上老年人、虛弱和惡病質(zhì)患者使用碘對(duì)比劑時(shí)，其不良反應(yīng)的發(fā)生率也高i)對(duì)比劑的外滲1)使用高壓注射器、注射流率高2)注射部位欠佳，包括下肢和遠(yuǎn)端小靜脈3)對(duì)比劑用量較大4)高滲對(duì)比劑5)不能進(jìn)行有效溝通配合者6)靜脈脆弱或受損7)淋巴和/或靜脈引流受損j)造成對(duì)比劑腎毒性的危險(xiǎn)因素：1)血清肌酐水平升高，尤其是繼發(fā)于糖尿病腎病2)脫水3)充血性心力衰竭5)合并使用腎毒性藥物，如非類固醇類抗炎藥k下列患者使用含碘對(duì)比劑后有發(fā)生甲狀腺功能亢進(jìn)的危險(xiǎn)：1)Grave,s病2)多結(jié)節(jié)性甲狀腺腫3)自主功能性甲狀腺腫4)老年患者和/或生活在飲食碘缺乏地區(qū)的患者敏反應(yīng)劑過敏反應(yīng)類型輕度過敏反應(yīng)7DB1283.4—2010。情較重。2中度過敏反應(yīng)迷等?！h(huán)系統(tǒng)：低血壓，偶發(fā)室性、房性期前收縮(早搏)及血管痙攣等。重度過敏反應(yīng)呼吸衰竭等。等。劑過敏反應(yīng)的受累器官及臨床表現(xiàn)——全身癥狀：不適、虛弱——皮膚、黏膜：球結(jié)膜水腫、鼻塞、血管性水腫或潮紅、發(fā)紺攣——消化道系統(tǒng)：蠕動(dòng)增強(qiáng)、嘔吐、吞咽困難、惡心、腸痙攣、腹瀉——心血管系統(tǒng)：心悸、心律失常、低血壓、冠狀動(dòng)脈灌流不足——冠狀動(dòng)脈痙攣：心臟停搏劑過敏反應(yīng)試驗(yàn)過敏試驗(yàn)術(shù)前準(zhǔn)備之一。8DB1283.4—2010過敏試驗(yàn)常用方法——皮內(nèi)注射方法：在前臂內(nèi)側(cè)用30％濃度對(duì)比劑注一小皮丘，10~15分鐘后，觀察皮丘紅斑的對(duì)比劑使用知情同意要：甚至潰爛、壞死等。潛在危險(xiǎn)。進(jìn)及腎功能狀態(tài)。注射碘對(duì)比劑檢查。員。防措施c前應(yīng)注意補(bǔ)液，評(píng)價(jià)其水電解質(zhì)平衡狀況并酌情糾正某些高危因素對(duì)臟器功能的影響，除。d)必要時(shí)給予預(yù)防性藥物9DB1283.4—20102)除皮質(zhì)類固醇外也可選用抗組胺類藥物，但意見有分歧。3)以往有嚴(yán)重對(duì)比劑遲發(fā)性不良反應(yīng)的患者可以口服類固醇。g)醫(yī)學(xué)影像學(xué)醫(yī)護(hù)人員要熟悉和掌握碘對(duì)比劑的性能、用量、禁忌癥以及過敏反應(yīng)的最佳處理i)具有對(duì)比劑腎毒性高危因素患者小2)使用低滲或等滲非離子型對(duì)比劑，不要使用高滲離子型碘對(duì)比劑。4)不要使用甘露醇和利尿劑，尤其是袢利尿劑。6)考慮不需要使用含碘對(duì)比劑的其它影像學(xué)技術(shù)。j)注射碘對(duì)比劑后有發(fā)生甲狀腺機(jī)能亢進(jìn)危險(xiǎn)因素患者1)部分高?；颊?，可由內(nèi)分泌醫(yī)生給予預(yù)防性治療，這在飲食碘缺乏的地區(qū)意義較大。2)不應(yīng)行靜脈注射碘對(duì)比劑。3)絕對(duì)禁忌癥：有明確甲狀腺機(jī)能亢進(jìn)表現(xiàn)的患者不能使用含碘對(duì)比劑。k)服用雙胍類降糖藥的糖尿病患者的對(duì)比劑應(yīng)用1)血管內(nèi)給對(duì)比劑前，應(yīng)當(dāng)測定血清肌酐水平2)應(yīng)當(dāng)使用低滲對(duì)比劑。3)擇期檢查：如果血清肌酐正常，應(yīng)當(dāng)在檢查當(dāng)天停用二甲雙胍，48小時(shí)內(nèi)不能重新/血清肌酐仍然在正常范圍內(nèi)時(shí)，才能重新使用。如果腎功能異有使用對(duì)比劑48小時(shí)后腎功能/血清肌酐無變化時(shí)，才4)急診病例：如果血清肌酐正常，按擇期檢查的患者一樣進(jìn)行檢查。如果腎功能異常(或不明)，臨床醫(yī)生應(yīng)當(dāng)權(quán)衡使用碘對(duì)比劑的利弊及考慮其它影像學(xué)技術(shù)。如果l)停用二甲雙胍治療。DB1283.4—2010m)適當(dāng)補(bǔ)液。建議每小時(shí)口服100ml生理鹽水至使用對(duì)比劑后24小時(shí)。條件允許者建議采用n)監(jiān)測腎功能(血清肌酐)、血清乳酸和血PH值。o)檢查有無乳酸酸中毒的癥狀(嘔吐、嗜睡、惡心、上腹痛、食欲減退、喘息、昏睡、腹瀉和p)預(yù)防對(duì)比劑外滲1)靜脈穿刺選擇合適的血管，操作細(xì)致。2)使用高壓注射器時(shí)，選用塑料導(dǎo)管針。3)選用低滲對(duì)比劑。4)與患者溝通，取得配合。q)避免對(duì)比劑與其它藥物相互作用1)了解患者的用藥史，做好對(duì)比劑注射的記錄(時(shí)間、劑量、名稱)。3)不要在導(dǎo)管或注射器中將對(duì)比劑與其它藥物混合。用中的監(jiān)測應(yīng)應(yīng)立即停止注射，保留血管內(nèi)針頭或?qū)Ч?，在整個(gè)X線檢查過程中應(yīng)始終保持靜脈輸液通介入治療時(shí)特別重要。影后的觀察1周內(nèi)出現(xiàn)的不良反應(yīng)。曾有報(bào)告對(duì)比劑給藥后可出現(xiàn)各種遲發(fā)性癥狀(例如：惡心、嘔吐、DB1283.4—2010理方法a)檢查室中必須備有的緊急用藥和器械1)簡易呼吸機(jī)2)氧氣3)1：1000腎上腺素4)組胺H1受體阻滯劑5)阿托品動(dòng)劑定量氣霧劑8)抗驚厥藥(安定)9)血壓計(jì)10)吸痰機(jī)11)聽診器b)如一旦確定不良反應(yīng)的發(fā)生，應(yīng)立即停止注射碘對(duì)比劑。c)保持呼吸道通暢。有資料顯示，過敏所致死亡40％是因?yàn)楹粑鷥斒д{(diào)所致，故氣道通暢e時(shí)給予液體治療，靜脈輸液，快速擴(kuò)容，使收縮壓維持在90mmHgf)使用腎上腺皮質(zhì)激素。雖然起效較慢，但可減少延遲復(fù)發(fā)的癥狀和不良反應(yīng)的程度。應(yīng)的對(duì)癥處理人應(yīng)DB1283.4—2010a)惡心/嘔吐1)一過性：支持治療2)嚴(yán)重、持續(xù)時(shí)間長者：應(yīng)當(dāng)考慮給予適當(dāng)?shù)闹雇滤?。b)蕁麻疹1)散發(fā)、一過性者：支持治療及觀察。.3ml(0.1－0.3mg)，肌肉中度反應(yīng)a)單純低血壓1)抬高患者下肢2)面罩吸氧(6－10升/分)3)靜脈補(bǔ)液：快速補(bǔ)充生理鹽水或乳酸林格氏液4)如果無效：腎上腺素：1︰1000，0.5ml(0.5mg)肌肉注射。必要時(shí)重復(fù)給藥。b)如血壓下降合并心動(dòng)過緩1)抬高患者下肢2)面罩吸氧(6－10升/分)(0.04mg/kg體重)。兒童患者給予0.02mg/kg體重靜脈注射(每次最大劑量0.6mg)。必要時(shí)重復(fù)給藥，總劑量可達(dá)2mg。4)靜脈補(bǔ)液：快速補(bǔ)充生理鹽水或乳酸林格氏液。c)如血壓下降伴呼吸困難d)支氣管痙攣1)面罩吸氧(6－10升/分)2)β2受體激動(dòng)劑定量氣霧劑(深吸2－3次)3)腎上腺素ml(0.1－0.3mg)(冠心病患者或老年患者使用較小的劑量)ml5mg)(兒童患者：0.01mg/kg體重，肌肉注射)e)喉頭水腫1)保持氣道通暢，必要時(shí)行環(huán)甲膜穿刺2)面罩吸氧(6－10升/分)應(yīng)a)全身過敏樣反應(yīng)1)保持氣道通暢，必要時(shí)氣道吸引，呼吸循環(huán)停止者應(yīng)立即進(jìn)行心肺復(fù)蘇術(shù)DB1283.4—20102)呼叫復(fù)蘇人員，緊急通知急診科、麻醉科配合搶救3)低血壓時(shí)抬高患者下肢4)面罩吸氧(6－10升/分)5)肌肉注射腎上腺素(1︰1000)，成人0.5ml(0.5mg)。必要時(shí)重復(fù)給藥。兒童6)靜脈補(bǔ)液(如生理鹽水，乳酸林格氏液)H1受體阻滯劑如苯海拉明25－50mg靜脈給藥b)腦水腫可用甘露醇對(duì)癥處理。d)有驚厥者，予以抗驚厥等對(duì)癥治療，采用抗過敏、補(bǔ)充血容量等治療手段，以促進(jìn)排泄。理措施比劑給藥。。WX劑DB1283.4—2010a)妊娠1)在特殊情況下，必須進(jìn)行影像學(xué)檢查時(shí)，孕婦可以使用含碘或釓的對(duì)比劑。3)妊娠期間母親使用含釓對(duì)比劑后，新生兒出生后不需要任何檢查。b)哺乳：母親使用含碘或含釓對(duì)比劑后可以繼續(xù)正常的哺乳。c)腎功能損害的孕婦或哺乳的母親使用含碘或釓對(duì)比劑，胎兒或新生兒無特殊注意事項(xiàng)。DB1283.4—2010參考文獻(xiàn)介入治療及護(hù)理.鄭州:河南科學(xué)技術(shù)出版社,2000[3]YamaguchiK,KatayamaH,TakashimaT,etal.PredictionofsevereadversereactionstoionicandnonioniccontrastmediainJapan:evaluationofpretesting.AreportfromtheJapaneseCommitteeontheSafetyofContrastMediaRadiology178:363-367[4]ThomsenHS,MorcosSK.Contrastmediaandmetformin:guidelinestodiminishtheriskoflacticacidosisinnon-insulin-dependentdiabeticsafteradministrationofcontrastmedia.ESURcontrastmediasafetycommitteeEurRadiol9,9:738-740[5]ThomsenHS,MorcosSK;MembersoftheContrastMediaSafetyCommitteeoftheEuropeanSocietyofUrogenitalRadiology(ESUR).InwhichpatientsshouldserumcreatininebemeasuredbeforeiodinatedcontrastmediumadministrationEurRadiol,2005,15:749-754[6]MorcosSK,ThomsenHS.JAWWebb;MembersoftheContrastMediaSafetyCommitteeoftheEuropeanSocietyofUrogenitalRadiology(ESUR).DialysisandContrastMedia.EurRadiol,,12:3026-3030[7]CochranST.Anaphylactoidreactionstoradiocontrastmedia.CurrAllergyAsthmaRep,2005,[8]ThomsenHS,AlménT,MorcosSK;MembersoftheContrastMediaSafetyCommitteeoftheEuropeanSocietyofUrogenitalRadiology(ESUR).Gadolinium-containingcontrastmediaforradiographicexaminationsapositionpaperEurRadiol2:2600-2605[9]ThomsenHS,MorcosSK;MembersoftheContrastMediaSafetyCommitteeoftheEuropeanSocietyofUrogenitalRadiology(ESUR).Managementofacuteadversereactionstocontrastmedia.EurRadiol,,14:476-481[10]WebbJA,StaculF,ThomsenHS,MorcosSK;MembersoftheContrastMediaSafetyCommitteeoftheEuropeanSocietyofUrogenitalRadiology.Lateadversereactionstointravasculariodinatedcontrast[11]WebbJA,ThomsenHS,MorcosSK;MembersofContrastMediaSafetyCommitteeofEuropeanSocietyofUrogenitalRadiology(ESUR).Theuseofiodinatedandgadoliniumcontrastmediaduringpregnancyandlactation.EurRadiol.2005,15(6):1234-40[12]侯建新,付孟麗,許玉林,等.CT增強(qiáng)掃描時(shí)對(duì)比劑外漏的原因分析及預(yù)防.泰山醫(yī)學(xué)院學(xué)報(bào),,26(1):63[13]林友岳,虞希祥,李陽,等.造影劑不良反應(yīng)的預(yù)防及處理探討.影像診斷與介入放射學(xué)，,9(4):250預(yù)防及處理.基層醫(yī)學(xué)論壇,2005,9(6):574[15]田桂琴,李紅梅.CT增強(qiáng)掃描中造影劑不良反應(yīng)的預(yù)防和處理.臨床醫(yī)藥實(shí)踐雜志:790-791造影劑不良反應(yīng)的預(yù)防及治療.武警醫(yī)學(xué),2004,15(7):537救護(hù)理與預(yù)防.齊魯護(hù)理雜志,2006,12(4):695-696[18]王碧珍,林翔鵬.CT增強(qiáng)掃描中造影劑不良反應(yīng)的預(yù)防及護(hù)理.現(xiàn)代醫(yī)藥衛(wèi)生,2005,21(23):0DB1283.4—2010JUseofcontrastagentsforliverMRIRadiographysupplee施的研究進(jìn)展.重慶醫(yī)學(xué),2007,36(1):87-92[23]ThomsenHS.Europeansocietyofurogenitalradiology(ESUR)guidelinesonthesafeuseofiodinatedcontrastmediaEuropeanJournalofRadiology2006;60(3):307-313[24]Kr?merBK,KammerlM,SchwedaF,SchreiberM.Aprimerinradiocontrast-inducednephropathy.NephrolDialTransplant9Dec;14(12):2830-4[25]McCulloughPA,WolynR,RocherLL,LevinRN,O'NeillWW.AcuterenalfailureaftercoronaryinterventionincidenceriskfactorsandrelationshiptomortalityAmJMedNov):368-75[26]McMurraySD,LuftFC,MaxwellDR,etal,PrevailingpatternsandpredictorvariablesinpatientswithacutetubularnecrosisArchInternMed978Jun;138(6):950-5[27]LevyEM,ViscoliCM,HorwitzRI.Theeffectofacuterenalfailureonmortality.Acohortanalysis.JAMA96May15;275(19):1489-94[28]KolonkoA,KokotF,WiecekA.Contrast-associatednephropathy--oldclinicalproblemandnewtherapeuticperspectivesNephrolDialTransplantMar;13(3):803-6[29]LautinEM,FreemanNJ,SchoenfeldAH,etal.Radiocontrast-associatedrenaldysfunction:acomparisonoflower-osmolalityandconventionalhigh-osmolalitycontrastmedia.AJRAmJlBergKJNeohrotoxicityrelatedtocontrastmediaScandJUrolNephrol0;34;317-22[31]AndersonRJ,LinasSL,BernsASetal.Nonoliguricacuterenalfailure.NEnglJMed.1977MayBergJRudinickMRadiocontrastmediaScandJUrolNephrol;34:317-22[33]FangLS,SirotaRA,EbertTH,LichtensteinNS.LowfractionalexcretionofsodiumwithcontrastmediainducedacuterenalfailureArchInternMedApr531-3[34]KatzbergRW.Urographyintothe21stcentury:newcontrastmedia,renalhandling,imagingnephrotoxicityRadiologyAugGGAcuterenalfailureLancet[36]RichMW,CreceliusCA.Incidence,riskfactors,andclinicalcourseofacuterenalinsufficiencyaftercardiaccatheterizationinpatients70yearso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