In some pain interventions, contrast media is used for imaging that visualizes the needle tip location for clinicians.
The temporary closure of a contrast media manufacturing facility in China for a COVID-19 lockdown is impacting some pain interventions, a pain medicine expert says.
The closure of the GE Healthcare facility in Shanghai, which makes iodine-based contrast media, is having a more widespread impact on radiology such as CT scans. The American College of Radiology has made several recommendations for imaging that requires iodinated contrast media.
The contrast media shortage is a concern in pain medicine, says David Dickerson, MD, chair of the American Society of Anesthesiologists Committee on Pain Medicine. He is also medical director of the Anesthesia Pain Services Department of Anesthesiology, Critical Care, & Pain Medicine at NorthShore University HealthSystem in Evanston, Illinois.
"In interventional pain care, we use contrast to visualize our needle tip location during procedures that are targeting inflamed or dysfunctional nerves, joints, or muscles. So, contrast is often used in spinal procedures to make sure that we are near the target that we want to be treating such as a nerve root before we deliver the medication. We want to make sure that our medicine goes to the right place and that the needle tip is not somewhere that can cause harm. Contrast is used with X-ray-guided procedures," Dickerson says.
The American Society of Regional Anesthesia and Pain Medicine has made several recommendations for pain interventions during the contrast shortage. One of the recommended alternatives to using contrast for pain interventions is using ultrasound, Dickerson says. "With ultrasound, you can visualize all of the soft tissue and you are able to see where your needle is in real-time. So, you can forgo using contrast with an ultrasound-guided approach."
Pain medicine specialists should not switch to gadolinium contrast for spinal procedures, he says. "We cannot switch from iodinated contrast to the gadolinium contrast used in MRI scans, which has not been affected by the contrast shortage. There have been cases of patients who have had injury from gadolinium getting into their spinal fluid during a spinal injection. Patients have lost consciousness, experienced confusion, and suffered neurologic injury."
Some procedures can be modified to use either approaches or drugs that do not require contrast as a part of the procedure, Dickerson says. "You might change your image guidance, or you might change your needle approach to be not in an area where blood vessels are located—you can use an alternative approach to get to the same target. That approach can avoid using contrast, and the efficacy or safety of the procedure is not compromised."
Contrast is required for one kind of epidural procedure, Dickerson says. "When doing something like a transforaminal epidural steroid injection, which is a nerve root injection for a herniated disc or disc bulge, there are a couple of different approaches to get steroid into the epidural space around the nerve root. One approach is to put the needle right next to the nerve root and introduce a small amount of medicine around the nerve root and the epidural space as well. That epidural is very targeted to the nerve root of interest, but it is also in a very vessel-rich area. So, contrast lets us know that we are in the right spot and that we don't need to move the needle tip a couple of millimeters to avoid putting the medicine into a wrong location."
He says two other epidural approaches achieve the same effect but do not require contrast: caudal or interlaminar epidurals. "Those approaches have us placing a needle tip or a tiny microcatheter that advances to the target and avoids being near blood vessels. That is one of the recommendations—if you do not have contrast available, consider using a caudal or interlaminar epidural, where you avoid the need for contrast."
Shortage expected to ease soon
There should be adequate supply of iodinated contrast soon, Dickerson says.
"The Shanghai facility that was shut down for a COVID lock down is back up and running. We have been told that by the end of June, we should have restoration of the supply chain. However, that assumes that there are no other hiccups. This is where we need to think about having redundancy in our supply chains."
Federal action may be required, he says. "We may need to work with members of Congress to ensure that we require the companies that import contrast have diversification of their supply chain. The companies that import iodinated contrast are exclusively bringing in the contrast from one facility in China. We could end up with geopolitical issues that affect that supply chain with very little room for flexibility or adapting outside of rationing."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
The iodinated contrast media shortage is also impacting radiology such as CT scans.
For some pain interventions, ultrasound imaging can replace imaging achieved through use of iodinated contrast media.
Pain specialists should not substitute iodinated contrast media with gadolinium contrast for spinal procedures.