Still Using a Contrast Warmer?

I get questions from colleagues around the country on a fairly regular basis. Every once in a while, there is a recurrent theme. Most recently, I have had questions related to the use of contrast media warmers.

Back in late 2006/early 2007, our pharmacy department received warnings/recommendations regarding noncompliance with contrast warmers — both during a Mock Survey conducted by the Joint Commission consultant and during a medication management consultation by a Joint Commission consultant. Contrast media are considered medications, and as such, their storage and use must comply with all of the medication management standards.

Medication Management Standard .2.20 also requires that medications are stored under conditions suitable for product stability. Currently, Visipaque (iodixanol) is the only contrast media with stability data of the heated product from the manufacturer. Per GE, it may be stored for up to one month (30 days) at 37˚C (98.6˚F) in a contrast agent warmer. Once in the warmer, the product would need to be labeled with the date it was placed inside, then discarded after 30 days. In addition, a daily temperature log must be maintained on all warmers to ensure that the temperature has remained in the recommended range. Digital thermometers with the ability to record temperature extremes (maximum high and low temperatures) must be utilized to ensure product stability during times when the area is not staffed.

I contacted all U.S. contrast manufacturers in 2007, and confirmed that Visipaque is the only contrast media with any stability data. I also sent out a mass group email to cath labs across the country asking about their use of contrast warmers. Of the labs that replied, only about 50% used warmers at that time. The labs experiencing recent Joint Commission visits have all discontinued use of warmers because of the regulatory requirements.

I also contacted via email several prominent cardiologists around the country, asking if any had, or were aware of, any studies on safety information r/t warmed vs. room temperature contrast and the incidence of arrhythmias. None of them had any information, nor could they recall ever seeing any. I could not find much literature related to the warming of contrast material; there was one (common sense) article suggesting that the viscosity of room-temperature contrast is higher than heated contrast. This would be most noticeable with 4-5F catheters (or 3F if you are doing peds). However, unless you are utilizing a mechanical contrast injector with a warmer jacket, or hanging your contrast bottles in a thermo jacket, the contrast media will reach your cath lab temperature in a matter of a few minutes of being hung.

So, the Cleveland Clinic eliminated use of contrast warmers back in 2007 because the lack of stability data (regarding the heating of contrast media) and the potential issues with daily documentation, which could lead to multiple "Requirements for Improvement" during a Joint Commission (or any accreditation) survey. Three years later, we have had no spike in either bradycardia or VT/VF with contrast injections.

Comments

This is good information. I will share your blog with the physicians and management to see what they would have me do with our contrast warmer. Thanks Kenneth.

Kenneth, Would it be possible for you to send me the information regarding warming of contrast medica. If it is only necessary for Visapaque we will no longer warm the solutin in our cath lab. Thanks Tammy

Haven't used one in years

What about for CT??

Hey thats pretty interesting. We have an automatic injector with contrast warmer attached but also keep our visipaque in warmer's all the time. With no monitoring of temp or how long the contrast has been in there.
What a waste of time! will circulate to our Dr's.
Cheers, Sarah

thank very much. we have different contrast media (xenitic)- if my write is correct- and most of the time we using contrast of room tempereture.

But, i have a question. in peds cases do you think that we have to dilute the contrast with small amount of heparine?

We use warmers for our contrast, currently using Isovue, heparinized saline and NS. We have posted on the warmer itself tempertures and time frames suitable for the products in the warmer. I asked today where we obtained our stability info. We use Chloraprep for access site prep. It is also in the warmer. Today I heard studies have been done stating it loses its effectiveness when warmed. Have you heard the same?

that's interesting. I would like to know what range of temperature that's kept in you cathlab.

We have stopped using the contrast media warmer without any general changes to outcome. One has to note that the power injector may warm the volume being injected.

Vincent Gatt
Malta

Yikes all! We just had our JCAHO visit and luckily I got my eyes on this article a few months back and implemented the dating on the bottles once we place them in the warmer, if you still have one. Sure enough, the JCAHO surveyor asked to see the bottles in the warmer and asked us what the date meant. I guess in addition to the date we placed it in the warmer, we also have to put the latest date we can keep it in there also, which would be the 30 days later. Make sure you put BOTH dates on the bottle. Getting rid of the whole thing sounds much less hectic! Good luck with all your visits!

Add new comment