Specializing in the contrast injector sector can be a tough gig. The technology has been around for decades and essentially, it’s a pump. There’s more to it of course, but when placed side-by-side with flashy pieces of equipment like MR or ultrasound, contrast injectors just aren’t sexy. Both those modalities rely on contrast injectors in order to carry out certain imaging procedures, but CT is probably the modality that puts contrast injectors to work the most. Approximately half of all CT exams use contrast, so 30 to 40 million. Still, profits from the sale of injectors pale in comparison to the income generated by consumables — the tubing, syringes and contrast, for example — with the machine the conduit to deliver and exhaust those supplies.

Although the big money in the sector is injected by contrast agents, the biggest players in the equipment equation — Bayer Healthcare and Bracco have made some notable improvements to the equipment over the years that may pique interest and get equipment sales moving as manufacturers gear up to create some must-haves for injectors in the near future.

Safety first
Unlike infusion pumps, a medical device somewhat notorious for high rates of recall, contrast injectors are relatively free from controversy. In part, it helps that physicians are typically at the patient’s side when the injector is being used. But even with a medical professional close at hand, there still can be problems such as allergic reactions to the contrast being used, extravasation or even renal failure.

Manufacturers have been at work developing solutions to give customers the tools needed to prevent any of those potential issues from becoming clinically significant.

The EmpowerCT Contrast Injection System was brought to market about a decade ago as a single head injector by E-Z-EM Inc. A dual-head, the EmpowerCTA came out later and the company was acquired by Bracco in 2008. In the ensuing years, Bracco has continued to build upon the technology offered in the the CT injector.

“The EmpowerCTA is the first injector to offer an extravasation detection accessory (EDA) solution,” says Kai Huang, Bracco product manager of Device Marketing. The EDA can detect extravasations and pause the CT procedure. The EDA can help prevent significant events from occurring.

The system also offers Saline Advance, an enhancement that was introduced in 2012. Saline Advance utilizes a pendant switch to advance saline to test vein integrity by the patient’s side. Coupled with Saline Advance is Saline Jump, which advances a contrast enhanced CT procedure from the contrast phase to saline, once the technologist receives the required diagnostic information.

“For example, on an abdomen contrast-enhanced procedure using 80ml contrast and 50ml of saline, if that patient has great vascular output and the technologist can get by with 60ml of contrast, they can bypass straight to the saline jump to complete the procedure, says Hung. “It allows the technologist to use the optimal amount of contrast required.”

Bracco received four-star recognition for general safety from ECRI Institute for the EmpowerCTA. “The base configuration of the EmpowerCTA was rated highest in safety by ECRI out of three with the other two being the Medrad Stellant D and what was then the Covidien Optivantage,” says Jason Launders, director of operations at ECRI Institute.

Launders says the criteria focused on making sure users follow proper steps to prime, addressing extravasation and air embolisation and integration with other systems. The other main player, Bayer, actually did slightly better on proper steps to prime. But integration and documentation are standard on Bracco’s product, which helped make the fourth star possible. It’s only optional on Medrad’s product.


However, when all the options were added in, Bayer and Bracco were rated equally at five stars. “What Medrad was doing and is still doing and what Bracco is following is the use of heart rate, respiration, the actual exams they’re trying to accomplish — they’re programming that all in and then the optimum parameters for that specific patient can be worked out,” says Launders.

As for Covidien’s machine, the Optivantage is now offered by Mallinckrodt after Covidien completed a spinoff of the pharma company in June of 2013.

Introducing integration
While patient safety is important, problems are rare enough that they don’t justify the purchase of new injectors for most facilities, especially in the current cost-cutting climate facilities are living in. Instead, efficiency that can increase patient throughput and, by extension, profitability, is a driving factor. Currently, one way efficiency can be ratcheted up is through improvements to equipment integration.

For years, most CTs and injectors have been connected to some extent. Until the CT is ready, the injector can’t be triggered for instance, but that’s been as far as integration has gone. More recently, the level of integration has increased dramatically. “Essentially the CT control console isn’t even needed — the CT injector is being controlled by the CT scanner,” says Launders.

“Bracco has taken that a step further,” says Launders. “With a very select number of CT scanners, they can link up and grab data from the CT like the patient’s heart rate for example. All that information can get grabbed by the injector.”

Bayer hasn’t been asleep at the wheel when it comes to improving its offerings either. “On the device side, we were the first company to launch a contrast informatics system,” says Dennis Durmis, head of the Americas region for Radiology & Interventional for Bayer HealthCare.” We’re looking at weight-based dosing and tying that information into the scanner, the RIS, the HIS, and the speech recognition system,” he says.

Bayer also has software called Radimetrics Enterprise Platform that ties into the management system to track total dose. The software was originally created by Radimetrics Inc. and became an asset when the company acquired Radimetrics in late 2012. The enterprise platform was showcased at RSNA last year and is available in the U.S. and Canada now. “It’s a single platform solution that manages radiation and contrast dose,” says Durmis. “It allows for data access in every area of the workflow.”

Whether the market’s ready to pay for the benefits of equipment integration remains to be seen, says Launders. “It’s difficult to make the case with ROI,” he says.

MR updates
The EmpowerMR Contrast Injection System is another offering from Bracco. “We have changed the industry with the first hydraulic MR injection system,” says Huang. “What makes Bracco’s EmpowerMR Injection System unique is the battery-free hydraulic system — which advantageously avoids risk of battery failure,” he says.

Another benefit is the fact that the system is MR conditional up to 7T. The unique design of the injection system has also improved workflow since there is no battery charging or changing.

Aiming for less
Technologists ideally want to deliver just the contrast needed to get the imaging procedure done. While it’s nice to have equipment that can adjust the release of saline to minimize the contrast’s length of stay, it’s even better for the patient when less contrast is introduced into the patient to start with.

Some of this can be controlled by using prefilled contrast syringes, especially with new sizes being offered. But prefilled can be problematic if there’s any type of issue with the procedure. If for instance, the patient’s vascular output doesn’t perform as expected, additional contrast may be needed. If there are prefilled syringes, some of the contrast may just go to waste. So software solutions are again stepping up to deliver the goods.

Solutions like having a pendant switch next to the patient that the technologist can use to see if they have a good IV can help. Having pressure readings displayed right on the injector head is another useful tool. Both are available with Bracco’s EmpowerCTA.

Along with reducing the use of contrast is the drive to optimize dose. For the last few years at least, this has been a major topic of discussion and it doesn’t look like it’s going to die down any time soon. For Bayer, this means working on technology to reduce both dose and procedure time. “We’re continuing to invest resources in minimizing exposure to both contrast and radiation,” says Durmis. “We’re really trying to leverage technology to support our customers,” he says.

Another new tool from Bracco is Nexo: The centralized, server-based system for standardized contrast delivery management. This IT solution connects CT injectors to the hospital’s RIS and PACS, addressing customers’ needs to centralize injector management, track contrast utilization, access patient-specific contrast history and key performance indicators.

Software tying into the EHR could help to deliver a better experience for patients in the future. “Collecting information out of the injector and automatically populating the EHR provides some very useful information,” says ECRI’s Launders. “You’ll know that the patient had this amount of contrast and this lot number and you’ll be able to track the optimal results better. You’ll be able to reduce the amount of contrast going into a patient,” he says.

That reduction will come as a relief to patients with any kidney related disease. However, there’s still the troubling occurrence of allergic reactions to contend with. “Allergic reactions aren’t something you can do anything about right now,” says Launders. He believes that may change in the future as contrast dose is tracked more closely and instances of reactions are better-documented and shared.

Maximizing uptime and looking to the future
Like any modality, contrast injectors benefit from a little TLC. With injectors readily carted around and contrast being a viscous substance, there are a number of things that can go wrong, putting the machines out of commission. Obviously, regular maintenance is highly recommended and with CMS’ decree, it’s a must anyway. But there are times that a problem can occur between regular schedules. For those times, rapid response can be a blessing to both patient scheduling and a facility’s bottom line.

Bayer’s answer is a remote technology called VirtualCare. “We’re wired into hospitals, so as soon as there’s a problem with an injector, we’re alerted immediately,” says Durmis. “A lot of times we can solve the problem over the phone.”

Bayer does still offer a feet-on-ground approach to equipment maintenance and also provides centralized repair and maintenance services such as calibrations for its own products as well as others through its Multi-Vendor Service offering.

Durmis believes the next level of innovation will not only be about continuing to have safe, reliable injectors, but also having the information technology capabilities within the modalities to help hospitals meet compliance requirements, stay efficient and stay very well-informed.

“I think the role of informatics and the tie-in of contrast procedure and device records are all going to play a more important role along with interconnectivity,” Durmis says. “I think those are the areas where you’re going to continue to see a lot of fresh perspectives and approaches.”


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DOTmed Registered HCBN April 2014 Injectors Companies

Names in boldface are Premium Listings.
Domestic
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed Certified
DOTmed 100
Scott Wasson, Radiology Services LLC, IN
DOTmed Certified
CARLOS sanchez, ion,llc, TX

International
Bruno Vandelanotte, Vandelanotte, Belgium