Practice Advisory: Contrast Agent Used in Pain Procedures Linked to Brain Damage and Death

An agent used off-label in interventional pain procedures has been linked to serious side effects and even death. Gadolinium-based contrast agents (GBCAs) are sometimes used in patients who have had previous hypersensitivity reactions to iodinated contrast medium. The agent has been associated with fibrosis of the skin and internal organs in individuals with compromised renal function, deposit and retention in the brain, brain damage (i.e., encephalopathy), and death.

In interventional pain medicine, contrast agents are used to guide targeted delivery of drugs to specific tissues or anatomic spaces. Traditionally, iodinated contrast medium is used, but some patients have had hypersensitivity reactions, ranging from hives to swelling of the larynx and even cardiovascular events. In these cases, some have recommended GBCAs as an alternative Approved by the FDA in 1988 for intravenous use to assist with radiographic imaging, GBCAs have enabled great advances in medicine such as identifying brain lesions on MRI. More than 300 million patients have received GBCAs worldwide.

When used in interventional pain procedures, GBCAs have been used as an alternative to iodinated contrast for spinal procedures. Unfortunately, inadvertent administration into the intrathecal space (i.e. subarachnoid space), has resulted in in adverse events including encephalopathy and death.

The American Society of Regional Anesthesia and Pain Medicine (ASRA) has joined with 10 other multinational and multispecialty organizations to issue a practice advisory on the use of GBCAs in interventional pain procedures based on a comprehensive review of the literature up to December 31, 2019. The practice advisory provides recommendations and risk statements to guide the physician in selection of GBCAs and management of potential adverse events.

The advisory was developed with representatives from nearly all pain societies in the United States to strengthen the recommendation and prevent duplication of effort. The final practice advisory was published March 23, 2021, in Anesthesia & Analgesia, a publication of the International Anesthesia Research Society.

ASRA Treasurer Dr. David A. Provenzano, who helped develop the guideline, is available for comment.