NURSING PATIENT CARE POLICY & PROCEDURE
To provide a process for intravenous administration of echocardiography contrast agents,
including those performed at the bedside that cannot be transported to the Heart and Vascular
Care Non-Invasive Diagnostic (NID) Testing Lab due to patient acuity, isolation requirements,
NOTE: This policy provides a process and does not delegate authority. Please refer to Protocol
57, IP/OP - Echocardiography Contrast Ordering by Sonographers in Adult Patients, for
All registered nurses including inpatient, outpatient, and emergency department, can administer
echocardiography contrast agents on any unit. The interpreting physician and/or sonographer will
determine whether the echocardiogram is of sufficient diagnostic quality or if the contrast agent
is needed. For pediatric patients, agitated saline is administered by the Pediatric Cardiology
Nurse Practitioners, Pediatric Cardiologist, or the Pediatric Intensive Care Attending Physician.
Echocardiography contrast agents are used to enhance the diagnostic quality of the
echocardiogram in technically difficult to image patients.
INDICATIONS – For use of contrast agents:
Perflutren Lipid Microsphere (Definity®) or Perflutren Protein Type A (Optison®):
• Enhancement of endocardial border for better observation of wall motion abnormalities
• Evaluation of LVEF assessment in uninterruptible studies
• Thrombus detection within the heart
• Improved accuracy in valve-flow measurements
• Presence of an atrial septal defect
• Presence of a patent foramen ovale
• Diagnosis of stroke (CVA) or transient ischemic attack
June 27, 2016
Feb. 28, 2017
Policy #: 10.24AP
Title: Administration of
Echocardiography Contrast Agents (Adult
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• Evaluate for hepatic fistula for pre liver transplant work ups
• Detect for potential embolic source
CONTRAINDICATIONS – The use of these agents is contraindicated in certain populations.
Perflutren contrast agents (only) will not be administered to any patients with the following
• Known hypersensitivity or known reaction to the contrast agent known as Definity®.
• Known hypersensitivity or known reaction to the contrast agent known as Optison®.
• Optison® contains albumin, contraindicated for patients with hypersensitivity to blood,
blood products or albumin.
• Do not administer perflutren by intra-arterial injection.
• Pediatric patients do not receive Perflutren.
PRECAUTIONS – The FDA revised the labeling information regarding perflutren in October,
2011 to state that “serious cardiopulmonary reactions including fatalities have occurred
uncommonly during or shortly following perflutren administration, typically within 30 minutes
of administration. The risk of these reactions may be increased among patients with unstable
• Acute coronary artery syndromes
• Worsening or unstable congestive heart failure
• Acute myocardial infarction
• Serious ventricular arrhythmias
IV. PERFLUTREN PROCEDURE FOR PATIENTS INCLUDING BEDSIDE
A. Sonographers will obtain and evaluate the echocardiographic images.
B. If the diagnostic quality of the study is sub-optimal, and if no contraindications are
present, the sonographer will order perflutren according to protocol (Protocol 57, IP/OP -
Echocardiography Contrast Ordering by Sonographers in Adult Patients).
The RN caring for the patient will be responsible for the administration of the perflutren
contrast agent. The sonographer will be responsible for performing limited follow-up
C. Perform hand hygiene according to UWHC Administrative Policy 13.08, Hand Hygiene.
D. Follow standard and transmission-based precautions according to UWHC Administrative
Policy 13.07, Standard Precautions & Transmission-based Precautions (Isolation) for
E. Contrast preparation and administration (these instructions are also available in an outline
format and will be provided by the NID personnel when they bring the medication):
1. Perflutren Lipid Microsphere (Definity®):
a. The sonographer will bring the supplies to the unit. Supplies will
include: spike adaptor, 10 mL normal saline flush syringe, 1 (1.5 mL)
vial contrast agent (Definity®).
b. The contrast agent Perflutren will be activated in the NID and brought to
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c. Administration: Insert the spike adaptor into a vial of well-shaken
perflutren (when shaken, perflutren will appear white). Vial should be
shaken for a full 45 seconds to activate. This is done by NID staff.
Waste 3 mL of normal saline from one of the 10 mL syringes of normal
saline. Withdraw the entire contents of a 1.5 mL vial of Definity®
contrast agent (without injecting air into the vial) into the remaining 7
mL of normal saline (total volume in syringe will be 8.5 mL). Use the
product immediately after withdrawal from the vial. After the perflutren
is diluted in the saline syringe administer the dilution to the patient using
a 1 to 2 mL slow IV push over 15-30 seconds. Echocardiography
contrast agents can be administered in any IV catheter size, including the
PowerPort on a PICC. More contrast agent may be needed for imaging
purposes. The sonographer will determine this based on image quality.
A total of 2 syringes, (containing two vials [3 mL] of Perflutren in 14
mL normal saline [total volume = 17 mL]) can be used on a patient.
d. Please note that this contrast agent leaves the patient’s system within 5-
10 minutes of administration.
2. Perflutren Protein Type A (Optison®):
a. The sonographer will bring the supplies to the unit. Supplies will
include: spike adaptor, 10 mL normal saline flush syringe, 1 (3 mL) vial
contrast agent (Optison®).
b. The vial is stored in the refrigerator. While allowing the vial to come to
room temperature, invert and gently hand rotate to resuspend the
microspheres. The solution should appear milky-white. Do NOT use if
solution is clear.
c. Administration: Insert the spike adaptor into the vial. Do NOT inject air
into the vial. Attach a 3 mL syringe on to the spike and withdraw the
contents of the Optison® vial.
d. Within 1 minute of resuspension, slowly inject 0.5 mL of Optison® into
a peripheral vein at a rate not to exceed 1 mL/second. Follow with a
slow flush with normal saline over 15-30 seconds, immediately after
injection. A central venous catheter may be used if no peripheral line is
available. Echocardiography contrast agents can be administered in any
IV catheter size, including the PowerPort on a PICC.
e. May repeat in increments of 0.5 mL not to exceed a total of 5 mL
cumulatively in 10 minutes (maximum total dose: 8.7 mL, slightly less
than three – 3 mL vials, in any one patient study).
F. Routine post medication administration monitoring will include observations for any
signs of acute reactions, including respiratory distress. If the patient begins to experience
any adverse reactions, a physician will be notified immediately and will assess the
patient. The RN will then be given further orders/instructions by the physician for how to
manage any adverse reactions.
G. The medication will be documented on the MAR.
H. Document a nursing note for this procedure in Health Link (Smart Text Selection:
3400058 UWIP NI CARD ECHO CONTRAST AGENT ADMINISTRATION). This
template will require the lot number and the expiration date printed on the vial of
Perflutren. If HealthLink Smart Text is not used, the RN should write a progress note
including the lot number and expiration date printed on the vial of Perflutren in the
clinical record. The RN should also document on the paper chart brought by NID staff.
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I. Dispose of any unused Perflutren, spike and vial in the red sharps container.
V. AGITATED SALINE PROCEDURE FOR PATIENTS INCLUDING BEDSIDE
A. Perform hand hygiene, when indicated, according to UWHC Administrative Policy
13.08, Hand Hygiene, and follow standard and transmission-based precautions according
to UWHC Administrative Policy 13.07, Standard Precautions & Transmission-based
Precautions (Isolation) for Inpatient Settings.
B. If the patient’s care team determines the need for and orders agitated saline contrast, then
an order for agitated saline contrast will be placed by the sonographer. Please refer to the
Protocol 57, IP/OP – Echocardiography Contrast Ordering by Sonographers in Adult
Patients, for delegation information.
C. Sonographers will obtain and evaluate the echocardiographic images. The RN caring for
the patient will be responsible for the administration of the agitated saline contrast agent.
The sonographer will be responsible for performing limited follow-up echocardiographic
images. For pediatric patients agitated saline is administered by the Pediatric Cardiology
Nurse Practitioners, Pediatric Cardiologist, or the Pediatric Intensive Care Attending
D. Agitated saline preparation and administration (these instructions are also available in an
outline format and will be provided by the NID personnel):
1. The sonographer will bring the supplies to the unit. Supplies will include: a large
bore 4-way stopcock with floating male Luer lock, (3) 10 mL normal saline flush
syringes, and a 10 mL syringe.
2. Administration: A patent IV is necessary (antecubital is preferred). Any IV
catheter size, including the PowerPort on a PICC, can be used. Attach the primed
stopcock to the IV. Using one of the normal saline flushes, discard 3 mL of
normal saline, pull back syringe to add 0.5 mL of air (total volume = 7.5 mL).
Attach this syringe to one port of the stopcock. Attach the empty syringe to the
other port of the stopcock. With the stopcock off to the patient, agitate the saline
by pushing the 7 mL of normal saline and 0.5 mL of air between the two syringes
several times vigorously, until many tiny bubbles appear. The sonographer will
tell the nurse when to rapidly administer the agitated saline bolus. The procedure
will be repeated with the patient performing the Valsalva maneuver. Prepare
another syringe by discarding 3 mL of saline from one of the syringe, and pull
back syringe of normal saline, add 0.5 mL of air, attach to the stopcock, turn
stopcock off to the patient and repeat the process to obtain the tiny bubbles. The
sonographer will give instructions to the patient for the Valsalva and instruct
nurse to rapidly administer the agitated saline bolus.
E. The medication will be documented on the MAR.
F. Document a nursing note for this procedure in Health Link using (Smart Text Selection:
3400060 UWIP NI CARD ECHO AGITATED SALINE ADMINISTRATION). If Smart
Text is not used, a progress note should be written. The nurse should also chart on the
VI. UWHC CROSS REFERENCES
A. UWHC Administrative Policy 8.17, Administration of Medications
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B. UWHC Administrative Policy 13.07, Standard Precautions & Transmission-based
Precautions (Isolation) for Inpatient Settings
C. UWHC Administrative Policy 13.08, Hand Hygiene
D. UW Health Clinical Policy 6.1.8, Administration of Intravenous Medications
E. Protocol 57, IP/OP – Echocardiography Contrast Ordering by Sonographers - Adult -
Inpatient/Ambulatory – Echo/Vascular Lab
A. Appis, A.W., Tracy, M.J. (2015). Update on the safety and efficacy of commercial
ultrasound cardiac applications. Echo Research and Practice, 2(2), 55-62.
B. Kurt, J., Shaikh, K., Peterson, L., Kurrelmeyer, K., Shah, G., Nagueh, S., Fromm, R., et
al. (2009). Impact of contrast echocardiography on evaluation of ventricular function and
clinical management in a large prospective cohort. Journal of the American College of
C. Porter, T. R., Abdelmoneim, S., Belcik. J. T., McCullock. M. L., Mulvagh, S. L., Olson,
J. J., . . . Wei, K. (2014). Guidelines for the cardiac sonographer in the performance of
contrast echocardiography: a focused update from the American Society of
Echocardiography. Journal of the American Society of Echocardiography, 27, 797-810.
D. Scope of Practice for the Diagnostic Ultrasound Professional. American Society of
Echocardiography. Retrieved from
VIII. REVIEWED BY
Nursing Education Specialist, Heart & Vascular
Manager and Technical Director, Echo/Vascular Care Laboratory
Drug Policy Program, February 2016
Nursing Patient Care Policy and Procedure Committee, April 2016
Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive