The shortage of iodinated contrast media (ICM) due to a General Electric (GE) manufacturing shutdown in Shanghai, China, is having profound effects on radiology practices globally.
As previously reported by Medscape Medical News, shortages of contrast media for CT imaging have been brought on by recent COVID-19 lockdowns in China. These shortages are expected to last until at least the end of June 2022. Most of the world's supply of contrast media is manufactured at a single Shanghai facility. The media are subsequently distributed by GE Healthcare.
"It is a very big deal at my hospital, and we are in emergency mode," said Justin M. Finn, MD, a diagnostic and interventional radiologist at Flagler Hospital, St Augustine, Florida. "Everything I do involves contrast."
Dealing with the shortage has involved making decisions as to how to conserve supplies while still providing patients with optimal care. For example, Finn explained that for diagnostic procedures, they've tried to perform as many evaluations as possible using modalities that do not require contrast media, rather than ones that do. "We are in line with the recommended substitutions, such as instead of brain CTAs, we will try to get brain MRAs," he told Medscape Medical News. "Instead of contrasted CTs, we'll try to get nuclear medicine bone scans, and so on."
At a clinical level, it is not only a huge inconvenience but can also affect patient care. "Some of the recommended alternatives have lower diagnostic acuity," Finn explained. "For example, a nuclear medicine perfusion scan is a very good scan and has less radiation than a PE [pulmonary embolism] study, but you're not going to pick up smaller PEs, and you're only given a risk score. A PE study is definitive and can alter management."
Using alternative options does "open us up to some misses," he said. "And there could be legal risks as well."
For instance, "If we want to rule out diverticulitis, that is something we can see with a noncontrasted scan," Finn said. "But what you may miss is a renal mass, because you can't fully examine the vasculature or the organs."
The American Roentgen Ray Society (ARRS) has issued management strategies to help facilities and imaging centers cope with the shortage. The guidelines were published in the American Journal of Roentgenology.
"Establishing awareness of the ICM shortage throughout the hospital system is an important first step," write co-authors Joseph Cavallo, MD, MBA, and Jay Pahade, MD, from the Department of Radiology and Biomedical Imaging at Yale's School of Medicine.
ICM play a primary role in the performance of contrast-enhanced CT (CECT), CTA, conventional angiography and venography, and fluoroscopic examinations. Even though only one agent — iohexol (Omnipaque) — is known to be directly affected by the closure of the Shanghai facility, the effects have rippled throughout what seems to be a relatively supply-constrained ICM market. The surplus supply of other ICM agents, such as iodixanol (Visipaque, GE), iopamidol (Isovue, Bracco), iopromide (Ultravist, Bayer), and ioversol (Optiray, Guerbet), has been quickly exhausted as radiology facilities have attempted to increase their inventories or find alternatives, write the ARRS authors.
They note that to continue to provide "optimal care for patients with emergent or life-threatening imaging indications and thereby minimize the overall impact on patient care, practice leaders will need to quickly assess their contrast material inventories, prioritize examination indications, and reduce their expected short-term usage of ICM."
Alerting hospital units that frequently refer for CECT, such as the oncology, surgery, and emergency departments, as well as other users of ICM (cardiology, vascular surgery, GI, radiation oncology, urology) can help align preservation strategies throughout the institution.
"The effects will be variable from place to place," Cavallo told Medscape. "Any facility that has very low supplies of ICM should already be functioning in a restricted capacity. There are multiple press reports of some places deferring nonurgent imaging or procedures, and nonurgent outpatient imaging will probably see the most deferments, due to its relative lack of acuity."
Cavallo pointed out that radiologists will likely be reading more noncontrast images that would routinely have been made with contrast. "In some cases, this could make it more difficult to make accurate diagnoses," he said. "Radiologists will also be consulted more frequently, as clinicians discuss individual patients to determine suitable alternative imaging."
Hospitals will probably seek more input from radiologists on which exams can be performed without contrast while still providing a high level of care. "Other than the specific tips related to direct ICM reduction which we have outlined in the paper, I would stress the necessity to work together with ordering physicians and consultants," Cavallo added.
The authors note that common indications for CECT can be stratified, according to necessity, using three primary means for reducing ICM usage: direct ICM dose reduction; alternative diagnostic imaging modalities or CT contrast agents; and deferment of imaging.
Finn noted that he and his colleagues have become very stringent with the amount of contrast they use and with which contrast they use. "We don't open up bottles unless we have to, and when we do open them, we use as little as possible," he said. "We dilute the contrast as much as we can while not impacting diagnostic quality. It's a diagnostic challenge as to how much we can dilute and not do the patient a disservice."
Finn described the situation as "scary...and very reminiscent of the days of the COVID pandemic when people were running out of masks. We never reused masks after a procedure, but then we were suddenly wearing them all day long. It became the new normal."
According to a May 12 advisory from the American Hospital Association, a GE Healthcare official said that the Shanghai facility has returned to 25% production capacity and that it hopes to reach 50% capacity within the next week. Some of the production has been moved to a plant in Cork, Ireland, and they have begun shipping to the US by air to speed deliveries. Although that development is encouraging, normal production is not expected to resume for at least another month.
Pahade is a consultant for GE Healthcare and Clario. Cavallo and Finn have disclosed no relevant financial relationships.
AJR Am J Roentgenol. Published May 13, 2022. Abstract
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Cite this: Roxanne Nelson. Radiologists Feeling the Effects of Contrast-Media Shortage - Medscape - May 16, 2022.