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.

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