Contraindicate patients:With a known hypersensitivity to EthiodolWith a right to left cardiac shuntWith advanced pulmonary disease, especially those with alveolar-capillary block.
Pulmonary gas diffusion studies should be done if in doubt.Who have had radiation therapy to the lungsProceed with caution:Patients having markedly advanced neoplastic disease with expected lymphatic obstruction.Patients having undergone previous surgery interrupting the lymphatic system.Patients having had deep radiation therapy to the examined area.If in those cases in which extreme caution should be exercised, lymphography is still necessary, a smaller dose of oily contrast medium with protracted injection time with less pressure and careful monitoring is required.Skin testing should be done on all patients before submitting them to lymphography.
Be aware of possible hypersensitivity to local anesthetics and skin disinfectants.
Careful history taking is important.Technique of cannulation: extravasation is to be avoided and/or detected early.
The injection site should be included on the "scout film" or observed under image amplification fluoroscopy.
The needle tip must remain visible in the incision wound.Oily contrast materials: once opened, ampules should be discarded.
Ampules of Ethiodol should not be used if the color has darkened or if particulate matter is present.
The average dose for each foot in an adult is 5 to 6 mL; one-half as much for the upper extremity.
The amount for children should be deter- mined by careful monitoring.
It should stay below 0.25 mL/kg.Injection pressure should be regulated to deliver the average dose in no less than 11/4 hours.
Continuous monitoring helps to determine the speed most appropriate for each individual.
Sensation of pain is a warning of too high pressure.Scout roentgenograms: if scout roentgenograms are used for monitoring, they should be developed and viewed immediately in order to apply corrective measures when needed; e.g., discontinuation of the study when one sees intravenous injection or lymphatico-venous anastomosis.
Reduction of injection speed is needed if evidence of collateral circulation occurs or if the higher abdomino-aortic nodes do not opacify in spite of the usual injection pressure.
This is highly suggestive of lymphatic obstruction.
Scout roentgenograms should be taken more frequently in such cases.Surgical technique: strict aseptic surgical technique is followed including the wearing of a face mask.
Before suturing the incision wound, the remnants of the lymphatic vessels and loose tissue are removed and the wound well washed with saline to remove any possible oil.
In case of reflux type lymphedema, the cannulated large lymphatic vessel may have to be closed by catgut to avoid development of a lymphocyst.The patient is instructed to elevate the legs as often as possible to promote healing.The sutures are removed from the feet on the 10th day, and on the 5th or 6th from the hands.
Ethiodol is contraindicated in patients hypersensitive to it.
Ethiodol should not be injected intrathecally or intravascularly or introduced into the bronchial tree.
Patients with known sensitivity to iodine should not have lymphography performed.
Iodine is split off from fatty compounds and becomes free iodine in the body.Lymphography is contraindicated in patients with a right to left cardiac shunt, in patients with advanced pulmonary disease, especially those with alveolar-capillary block, and in patients who have had radiotherapy to the lungs.
The use of intralymphatic Ethiodol presents a significant hazard in patients with pre-existing pulmonary disease characterized by a decrease in pulmonary diffusing capacity and/or pulmonary blood flow.
A few fatalities have been noted in such patients.
With reference to this potential complication, recent studies indicate a significant decrease in both pulmonary diffusing capacity and pulmonary capillary blood flow following Ethiodol lymphography without appreciable concomitant clinical manifestations.
Also, care should be exercised in patients with other types of pulmonary disease in view of the more frequent incidence of overt pulmonary complications such as pulmonary infarction, in these groups.However, it is to be noted that pulmonary infarction, although rare, has occurred in patients without evidence of pre-existing pulmonary disease.The safety of intralymphatic Ethiodol has not been established in pregnant women, and accordingly, its use should be restricted to such situations where it is deemed necessary.