Lipiodol injection (Ethiodized oil) is a radio-opaque contrast agent that is used during diagnostic procedures like hysterosalpingography, lymphography, and for the diagnosis of hepatocellular carcinoma.

Lipiodol Injection Uses:

• Hysterosalpingography:

  • lipiodol is a radiopaque contrast agent for hysterosalpingography in adults

• Lymphography:

  • It is also used radiopaque contrast agent for lymphography in adults and pediatric patients

• Selective hepatic intra-arterial injection:

  • It can also be used as imaging of hepatic tumors by injection into the arterial system. More specifically with HCC.

Lipiodol Injection Dose in Adults:

It is recommended to use the smallest possible dose based on the anatomical area to be visualized. The dose varies from the procedure to procedure.

Lipiodol Injection Dose in the Hysterosalpingography:

• It should be injected in 2 mL increments into the endometrial cavity until tubal patency is seen. Withhold use if excessive discomfort develops.
• Repeat imaging can be done after 24 hours to determine if ethiodized oil has entered the peritoneal cavity or not.

Lipiodol Injectioin Dose in the Lymphography:

• It should be noted that dye is injected into the lymphatic vessels under radiological monitoring.
• Injections should be stopped if the patient experiences pain. Withhold injection if a lymphatic blockage is present.
• This is to minimize entry into the venous circulation via lymphovenous channels.
• As soon as ethiodized oil is radiographically evident in the thoracic duct.
• Obtain immediate post-injection images. Repeat images at 24 or 48 hours to evaluate nodal architecture.
  • Unilateral lymphography of upper extremities: 2 to 4 mL
  • Unilateral lymphography of lower extremities: 6 to 8 mL
  • Penile lymphography: 2 to 3 mL
  • Cervical lymphography: 1 to 2 mL

Lipiodol Injection Dose in the Selective hepatic intra-arterial injection:

It is noteworthy that dose depends on tumor size and local blood flow in the liver and tumor.

• The dosage range is 1.5 to 15 mL administered slowly under continuous radiologic monitoring.
• Stop administration when stagnation or reflux is evident. The dose should be limited to the quantity required for adequate visualization. The  maximum total dose is 20 mL

Lipiodol Injection Dose in the Lymphography:

• Infants, Children, and Adolescents:

  • It is given in injection of 1 to 6 mL according to the area to be visualized.
  • The maximum dose is 0.25 mL/kg/dose.
  • Use the smallest possible dose based on the anatomical area to be visualized.  The dose varies with the site and size.

• It should be noted that dye is injected into the lymphatic vessels under radiological monitoring.
• Injections should be stopped if the patient experiences pain.
• Withhold injection if the lymphatic blockage is present.
• This is to minimize entry into the venous circulation via lympho-venous channels.
• As soon as ethiodized oil is radiographically evident in the thoracic duct.
• Obtain immediate post-injection images. Repeat images at 24 or 48 hours to evaluate nodal architecture.

Lipoidal Injection Pregnancy Risk Factor C

• The pregnancy has not been affected by oral administration of the drug in animals. The data on humans are limited.
• It can cause thyroid dysfunction in newborns, and it can also happen to humans. Hypothyroidism and permanent brain damage can result.

Lipiodol use during breastfeeding:

• Breast milk is known to contain lipiodol. In such cases, breastfeeding is not recommended. However, it is important to monitor your thyroid function regularly.

Dose in Kidney Disease:

No dose adjustment is required in renal impairment.

Dose in Liver disease:

There are no specific dose adjustments required in chronic liver disease.

Side effects of Lipiodol Injection:

• Cardiovascular:

  • Cerebral Embolism
  • Ischemia (Hepatic; Exacerbation)
  • Portal Hypertension (Exacerbation)
  • Pulmonary Embolism

• Hepatic:

  • Hepatic Failure (Exacerbation)
  • Hepatic Insufficiency (Irreversible)
  • Hepatic Vein Thrombosis

• Hypersensitivity:

  • Anaphylactoid Reaction
  • Anaphylaxis

Contraindications to Lipiodol Injection:

Hypersensitivity to ethiodized oils is a serious contraindication. Hyperthyroidism, major bleeding and hyperthyroidism are other risk factors

Contraindications for Hysterosalpingography:

• Pregnancy,
• Acute pelvic inflammation disease
• Symptoms of cervical erosion include:
• Inflammation of the endometrium and intrauterine bleeding
• In the immediate pre- and postmenstrual phases, or
• Within 30 days of curettage/conization

Contrainidcations in Lymphography

• Right to left cardiac Shunt
• Advanced pulmonary disease
• Hemorrhage or tissue trauma,
• Advanced neoplastic Disease with Expected Lymphatic Obstruction
• Previous surgery may have caused an interruption in the lymphatic system.
• Radiation therapy is applied to the affected area.

It is not recommended that dilated liver ducts be present unless an external biliary drain was done before the injection of Selective hepatic intraarterial injection.

Canadian labeling: Additional contraindications, but not in the US labeling

• Bronchography.
• Except for select users, IV, intrathecal or intra-arterial.
• Acute parotitis

Warnings and precautions

• Hypersensitivity

  • Anaphylactic reactions may be fatal and should be treated immediately.
  • Patients with allergies, asthma, bronchial asthma or a history of hypersensitivity to other iodine based contrast media should not use it.
  • It is important to have equipment for resuscitation available and personnel who are trained in handling emergency situations.
  • Most reactions are within 30 minutes. Some delayed reactions can occur for several days following administration.
  • Do not leave the room for more than 30 seconds after administration.

• Thromboembolism [US Boxed Warning]

  • Inadvertent intravascular injections or intravasation ethiodized oils can cause cerebral and pulmonary embolism. It can occur right away or within a few hours to days.
  • Avoid exposure to patients with severe impaired lung function, cardiorespiratory dysfunction, or right-sided cardiac overload.
  • Do not exceed the maximum dose during radiological imaging
  • You can reduce the risk of pulmonary embolism by having intra-lymphatic fluid confirmed radiographically.
  • If ethiodized oils become visible in the thoracic tube or lymphatic obstruction, discontinue use.

• Liver disease

  • Patients receiving intra-arterial hepatic hepatic administration should exercise caution. 
  • There are risks associated with the procedure, including vascular complications and infection.
  • Portal hypertension may be exacerbated by intra-arterial hepatic use. 
  • Hepatic ischemia can cause liver enzyme elevations and fever. Hepatic encephalopathy could result.
  • Reports of hepatic vein thrombosis and irreversible liver failure, as well as death, have been made.

• Thyroid disease:

  • The administration of iodinated, contrast media may lead to hypothyroidism or hyperthyroidism. 
  • Patients who have had thyroid radiation or are at high risk for developing Hashimoto thyroiditis, latent hyperthyroidism, or hypothyroidism should be cautious about using it.
  • Diagnostic tests can be affected up to two years after lymphography.

Lipiodol (ethiodized oil): Drug Interaction

Monitoring parameters:

• Renal function prior to administration and after administration in patients with a history of renal impairment.
• observe for hypersensitivity reactions for at least 30 minutes following administration.

How to administer Lipiodol Injection?

• Ethiodized oil is a clear, pale yellow to amber colored oil; do not use it if the color has darkened.
• Draw solution into a disposable syringe and use promptly; discard any unused portion of Lipiodol.
• For intralymphatic, intrauterine, and selective hepatic intra-arterial use only. The route of administration varies by indication.

Hysterosalpingography:

• Inject into the endometrial cavity with fluoroscopic control.

Lymphography:

• Inject into a lymphatic vessel under radiologic guidance to prevent inadvertent venous administration or intravasation.

Upper or lower extremities administration:

• Start injection into the lymphatic channel at a rate not to exceed 0.2 mL/min. The total dose should be injected in no less than 1.25 hours.

Selective hepatic intra-arterial injection:

• Inject amount slowly under continuous radiologic monitoring.

Mechanism of action of Lipiodol Injection:

Ethiodized oil can be used as a radiopaque contrast agents. It is composed of iodine and ethyl esters fatty acids from poppy seed oil. This is primarily as ethyl monoiodostearate or ethyl triiodostearate.

TimeHepatic:

• • It takes approximately 2 to 4 weeks for intra-arterial administration. Hepatocellular carcinoma has a longer retention time in the liver tumor.

International Brand Names of Lipiodol Injection:

• Lipiodol

Lipiodol Injection Brand Names in Pakistan:

No Brands Available in Pakistan.