This document provides guidelines for contrast reactions and their management from the American College of Radiology (ACR). It discusses various types of intravenous contrast media and their risks. Adverse reactions can range from mild to severe/life-threatening and include contrast-induced nephrotoxicity and nephrogenic systemic fibrosis. The document outlines Boston Medical Center's premedication regime using steroids and antihistamines to reduce reaction risk. It also provides guidance on assessing and treating acute contrast reactions according to their severity per ACR guidelines.
This document discusses key concepts in clinical pharmacology and therapeutics as they relate to a case study of a 67-year-old patient. It covers drug-drug, drug-disease, and drug-patient interactions to consider for the patient's medications. It proposes a therapeutic regimen for the patient and monitoring criteria. It also reviews principles of pharmacodynamics, how drugs act in the body, and pharmacokinetics, what the body does to drugs, including absorption, distribution, metabolism and excretion.
1. Radiocontrast agents, also known as contrast media, are substances used to improve the visibility of internal organs and structures during medical imaging. The most common types are iodine-based agents used for computed tomography and angiography, and gadolinium-based agents used for magnetic resonance imaging.
2. Contrast-induced nephropathy (CIN) refers to acute kidney injury caused by radiocontrast agents in patients with underlying renal impairment or risk factors. Preventing CIN involves identifying at-risk patients, minimizing contrast volume, using iso-osmolar or low-osmolar agents, intravenous hydration before and after exposure, and holding nephrotoxic drugs like metformin.
3
Various forms of contrast media have been used to improve medical imaging.
• Their value has long been recognized, as attested to by their common daily use
in imaging departments worldwide.
• Like all other pharmaceuticals, however, these agents are not completely devoid
of risk.
• Adverse side effects from the administration of contrast media vary from minor
physiological disturbances to rare severe life-threatening situations.
• Preparation for prompt treatment of contrast media reactions must include
preparation for the entire spectrum of potential adverse events and include
prearranged response planning with availability of appropriately trained
personnel, equipment, and medications.
• Thorough familiarity with the presentation and emergency treatment of
contrast media reactions must be part of the environment in which all
intravascular contrast media are administered.
1. Mikael, a 28-year-old male with AIDS, was hospitalized for toxoplasmosis while on ART. A change in ART is recommended due to clinical treatment failure from a new opportunistic infection.
2. Factors to consider when changing ART include prior treatment history, resistance testing, side effects, adherence barriers, and monitoring procedures. Reasons for changing include treatment failure, toxicity, and co-morbidities like pregnancy or tuberculosis.
3. Yared, a 30-year-old man stable on ART for 4 years, shows immunologic and virologic treatment failure. Additional information is needed on his adherence and potential resistance before selecting an alternative regimen.
This document discusses contrast reactions and their management. It begins by stating that contrast reactions can range from minor to life-threatening. Proper preparation is needed to treat all potential adverse events. Risk factors for reactions include previous reactions, renal insufficiency, and medications. Reactions are classified as idiosyncratic or non-idiosyncratic. Idiosyncratic reactions are unpredictable and severe. Non-idiosyncratic reactions depend on properties of the contrast agent like osmolality. Management involves stabilizing airway, breathing, and circulation. Specific treatments are outlined for mild, moderate, and severe reactions like urticaria, bronchospasm, and hypotension.
Steroid use in stroke treatment is controversial. Steroids may reduce brain edema and inflammation but also increase risks. The document discusses several studies on steroid use in different stroke types. It found no clear evidence that steroids improve outcomes in acute ischemic or hemorrhagic stroke. Steroids are only definitively indicated for stroke caused by vasculitis. Evidence is mixed for their use in subarachnoid hemorrhage. In general, the document concludes steroids have limited role in stroke therapy based on available clinical trials.
This document discusses a case of a patient diagnosed with non-Hodgkin lymphoma (NHL). Key details include:
- The patient has signs and symptoms consistent with NHL such as fever, night sweats, and weight loss. Imaging and labs also confirm NHL.
- The patient's disease stage is determined using an appropriate staging system. Factors like elevated LDH and low albumin affect his prognosis.
- Goals of therapy are to maximize curability while minimizing short and long term complications.
- The recommended treatment regimen is R-CHOP chemotherapy given every 3 weeks for 6 cycles. This includes rituximab, cyclophosphamide, doxorubicin, vincristine,
The document discusses the management of patent ductus arteriosus (PDA) in preterm infants. PDA occurs in 31% of very low birth weight infants and can be left untreated in some cases. Treatment may include conservative management, pharmacological closure with drugs like indomethacin or ibuprofen, or surgical ligation if drugs fail. Prophylactic drug treatment may help prevent complications in very preterm infants under 25 weeks gestation. The optimal management of PDA in infants under 800g is still debated, as untreated PDA carries risks but interventions also pose dangers.
This document discusses key concepts in clinical pharmacology and therapeutics as they relate to a case study of a 67-year-old patient. It covers drug-drug, drug-disease, and drug-patient interactions to consider for the patient's medications. It proposes a therapeutic regimen for the patient and monitoring criteria. It also reviews principles of pharmacodynamics, how drugs act in the body, and pharmacokinetics, what the body does to drugs, including absorption, distribution, metabolism and excretion.
1. Radiocontrast agents, also known as contrast media, are substances used to improve the visibility of internal organs and structures during medical imaging. The most common types are iodine-based agents used for computed tomography and angiography, and gadolinium-based agents used for magnetic resonance imaging.
2. Contrast-induced nephropathy (CIN) refers to acute kidney injury caused by radiocontrast agents in patients with underlying renal impairment or risk factors. Preventing CIN involves identifying at-risk patients, minimizing contrast volume, using iso-osmolar or low-osmolar agents, intravenous hydration before and after exposure, and holding nephrotoxic drugs like metformin.
3
Various forms of contrast media have been used to improve medical imaging.
• Their value has long been recognized, as attested to by their common daily use
in imaging departments worldwide.
• Like all other pharmaceuticals, however, these agents are not completely devoid
of risk.
• Adverse side effects from the administration of contrast media vary from minor
physiological disturbances to rare severe life-threatening situations.
• Preparation for prompt treatment of contrast media reactions must include
preparation for the entire spectrum of potential adverse events and include
prearranged response planning with availability of appropriately trained
personnel, equipment, and medications.
• Thorough familiarity with the presentation and emergency treatment of
contrast media reactions must be part of the environment in which all
intravascular contrast media are administered.
1. Mikael, a 28-year-old male with AIDS, was hospitalized for toxoplasmosis while on ART. A change in ART is recommended due to clinical treatment failure from a new opportunistic infection.
2. Factors to consider when changing ART include prior treatment history, resistance testing, side effects, adherence barriers, and monitoring procedures. Reasons for changing include treatment failure, toxicity, and co-morbidities like pregnancy or tuberculosis.
3. Yared, a 30-year-old man stable on ART for 4 years, shows immunologic and virologic treatment failure. Additional information is needed on his adherence and potential resistance before selecting an alternative regimen.
This document discusses contrast reactions and their management. It begins by stating that contrast reactions can range from minor to life-threatening. Proper preparation is needed to treat all potential adverse events. Risk factors for reactions include previous reactions, renal insufficiency, and medications. Reactions are classified as idiosyncratic or non-idiosyncratic. Idiosyncratic reactions are unpredictable and severe. Non-idiosyncratic reactions depend on properties of the contrast agent like osmolality. Management involves stabilizing airway, breathing, and circulation. Specific treatments are outlined for mild, moderate, and severe reactions like urticaria, bronchospasm, and hypotension.
Steroid use in stroke treatment is controversial. Steroids may reduce brain edema and inflammation but also increase risks. The document discusses several studies on steroid use in different stroke types. It found no clear evidence that steroids improve outcomes in acute ischemic or hemorrhagic stroke. Steroids are only definitively indicated for stroke caused by vasculitis. Evidence is mixed for their use in subarachnoid hemorrhage. In general, the document concludes steroids have limited role in stroke therapy based on available clinical trials.
This document discusses a case of a patient diagnosed with non-Hodgkin lymphoma (NHL). Key details include:
- The patient has signs and symptoms consistent with NHL such as fever, night sweats, and weight loss. Imaging and labs also confirm NHL.
- The patient's disease stage is determined using an appropriate staging system. Factors like elevated LDH and low albumin affect his prognosis.
- Goals of therapy are to maximize curability while minimizing short and long term complications.
- The recommended treatment regimen is R-CHOP chemotherapy given every 3 weeks for 6 cycles. This includes rituximab, cyclophosphamide, doxorubicin, vincristine,
The document discusses the management of patent ductus arteriosus (PDA) in preterm infants. PDA occurs in 31% of very low birth weight infants and can be left untreated in some cases. Treatment may include conservative management, pharmacological closure with drugs like indomethacin or ibuprofen, or surgical ligation if drugs fail. Prophylactic drug treatment may help prevent complications in very preterm infants under 25 weeks gestation. The optimal management of PDA in infants under 800g is still debated, as untreated PDA carries risks but interventions also pose dangers.
This document discusses several anesthetic complications that can occur during pregnancy, including thrombocytopenia/epidural hematoma, aspiration, difficult airways, and neuraxial blockade complications. Key points include: 1) There is no minimum platelet count that absolutely contraindicates neuraxial procedures, but less than 100,000 is often quoted as a threshold. 2) Pregnancy increases the risk of aspiration due to anatomical changes, so all pregnant patients are considered at high risk of aspiration. 3) Airway management can be difficult in pregnancy due to edema and weight gain; facilities should be prepared with multiple airway devices and surgical options. 4) Neuraxial blockade commonly causes hypotension due to sympathetic blockade,
This document provides information on contrast induced nephropathy (CIN), including its definition, pathogenesis, risk factors, incidence, prevention, and management. CIN is a form of acute kidney injury caused by radiocontrast media administration that results in an increase in serum creatinine levels within 3 days. Prevention focuses on hydration, using low- or iso-osmolar contrast agents, avoiding repetitive procedures, and discontinuing nephrotoxic drugs. Treatment is supportive as CIN is generally reversible with hydration and supportive care.
OMEPRAZOLE AND CLOPIDOGREL INTERACTION: CURRENT RECOMMENDATIONSDoc Tony Comia
- Omeprazole reduces the effectiveness of clopidogrel by almost half when taken together due to drug interaction where omeprazole blocks clopidogrel's conversion to its active form.
- Dual antiplatelet therapy with aspirin and clopidogrel is recommended for patients with acute coronary syndromes or stents to reduce risks of cardiovascular events, while a proton pump inhibitor is recommended to reduce risks of gastrointestinal bleeding.
- Recent evidence and meta-analyses suggest the interaction between proton pump inhibitors and clopidogrel does not significantly increase cardiovascular risks for most patients, and no significant differences in risks exist between individual proton pump inhibitors.
This document discusses various drugs used in dentistry, including antibiotics, antifungals, and antivirals. It provides information on the classes, indications, contraindications, side effects and precautions for commonly used medications like penicillin, amoxicillin, metronidazole, fluconazole, acyclovir and valaciclovir. Guidelines are also presented on the appropriate use of antibiotics for conditions like dental infections and the prophylactic use of antibiotics for certain medical conditions undergoing dental procedures.
This document provides an overview of anticoagulants including their mechanisms of action, indications, dosing, and monitoring. It discusses normal hemostasis and coagulation factors. Unfractionated heparin, low molecular weight heparins, and factor Xa inhibitors are described as parenteral anticoagulants. Oral anticoagulants reviewed include warfarin, rivaroxaban, apixaban, and dabigatran. The roles of clinical pharmacists in managing anticoagulation therapy are also mentioned.
This document summarizes the toxicity of oral anticoagulants and related drugs. It discusses how oral anticoagulants like warfarin work by inhibiting vitamin K, which is necessary for blood clotting. It outlines the narrow therapeutic window and need for monitoring with drugs like warfarin. It describes potential toxic effects like bleeding, skin necrosis, and birth defects if taken during pregnancy. Treatment involves investigating coagulation factors, stabilizing the patient, giving vitamin K as an antidote, and supporting bleeding patients with blood products or fresh frozen plasma.
This document provides an overview of enhanced recovery after surgery (ERAS) protocols. It discusses the history and phases of ERAS, including preoperative, intraoperative, and postoperative considerations. Specifically, it outlines strategies to optimize patient nutrition and exercise preoperatively, prevent hypothermia and infections intraoperatively, and promote early mobilization postoperatively. The overall goal of ERAS is to implement a multimodal, evidence-based approach to accelerate patient recovery through the perioperative period.
The document provides a review of therapeutic strategies for acute lung injury and acute respiratory distress syndrome (ARDS) based on published evidence and guidelines. It summarizes definitions of severe ARDS, initial evaluation and interventions including low tidal volume ventilation and conservative fluid management. Further strategies discussed include recruitment maneuvers, high positive end-expiratory pressure, prone positioning, high-frequency oscillatory ventilation, inhaled nitric oxide, glucocorticoids, and extracorporeal life support. Recommendations are provided for each strategy based on risks, benefits, and evidence from clinical trials.
This document discusses principles of antibiotic use in critical care. It notes that up to 50% of antibiotics prescribed are inappropriate and outlines consequences like increased resistance. The key principles for appropriate use are described as using the right antibiotic, at the right time, duration and dose based on the patient's condition and likely pathogens. Factors affecting pharmacokinetics and pharmacodynamics in critical illness are also reviewed to optimize dosing for better outcomes.
This document discusses new-onset diabetes after transplantation (NODAT), which occurs in some patients after receiving a solid organ transplant. It defines NODAT and reviews its epidemiology and risk factors. The document outlines the pathogenesis and risk of NODAT associated with different immunosuppressive drugs. It also discusses the diagnosis, screening, and management of NODAT, including monitoring patients, treating hyperglycemia, and controlling cardiovascular risk factors. The document notes ongoing areas of uncertainty around preventing NODAT and determining the long-term impacts of improved glycemic control.
Dr. Ranjita Acharya discusses perioperative medication management and which medications should be continued or stopped before surgery based on their medical condition. Key points include continuing most cardiovascular medications like beta blockers and antihypertensives to prevent rebound effects, holding diuretics and ACE inhibitors due to surgical risks, and consulting with specialists on anticoagulants and chemotherapy drugs. The presentation provides guidance on cardiovascular, endocrine, neurological, respiratory and gastrointestinal medications to optimize patient safety and surgical outcomes.
Gentamicin is an aminoglycoside antibiotic commonly used to treat early and late onset neonatal sepsis. It is effective against many gram-negative bacteria. Gentamicin is administered intravenously over 30 minutes, with dosage and interval depending on gestational and postnatal age. Therapeutic drug monitoring includes checking peak and trough levels. Adverse effects include nephrotoxicity and ototoxicity. Research is exploring using gentamicin to suppress cystic fibrosis mutations. Gentamicin use in the NICU requires careful monitoring and coordination between the medical team and nursing staff.
Antibiotic Strategy in Lower Respiratory Tract Infections (part 1)Gamal Agmy
This document summarizes guidelines for empiric antibiotic treatment of lower respiratory tract infections such as community-acquired pneumonia. It recommends using a clinical prediction rule like the Pneumonia Severity Index in addition to clinical judgment to determine whether patients should be treated as outpatients or inpatients. For outpatient treatment of CAP, it recommends amoxicillin, doxycycline, or macrolides depending on patient risk factors and local resistance patterns. For inpatient treatment of non-severe CAP without risk of MRSA or Pseudomonas, it recommends beta-lactam plus macrolide or fluoroquinolone monotherapy. It does not recommend routinely adding anaerobic coverage or extended-spectrum antibiotics without
Treatment for systemic lupus erythematosus (SLE) should be tailored to each patient based on an assessment of disease activity, damage, and comorbidities. Lupus nephritis, a form of kidney involvement, affects about 1/3 of SLE patients and can lead to end-stage renal disease if not properly treated. Treatment involves immunosuppressive drugs like corticosteroids, cyclophosphamide, mycophenolate, and azathioprine to induce remission based on the class of lupus nephritis determined by renal biopsy. Prognosis is generally good if treatment can normalize kidney function and blood pressure.
Author: Danielle Cassidy, PharmD, BCPS
Audience: Third year pharmacy students at University of Colorado School of Pharmacy & Oregon State University College of Pharmacy.
Background: Provides overview of common causes of pediatric venous thromboembolism & treatment management.
Introduction to pharmaceutical care of geriatric G eriatric pptxmalik1ajlan
- Older patients commonly experience drug-related problems like polypharmacy and inappropriate prescribing that can lead to adverse health outcomes.
- It is important for clinicians to understand age-related physiological changes like reduced renal function and how those changes impact pharmacokinetics and pharmacodynamics.
- Health care utilization and costs increase substantially with age, as older adults use more services and have longer hospital stays on average. Managing medications can help address issues like polypharmacy and adverse drug events.
Nephrotic syndrome is characterized by heavy proteinuria, hypoalbuminemia, edema, and hyperlipidemia. The most common cause is minimal change disease. Treatment involves corticosteroids as initial therapy, with cyclophosphamide or other immunosuppressants used for frequent relapses or steroid resistance. Supportive care focuses on managing edema, diet, and preventing infections, which are a major complication. Kidney biopsy may be needed to identify underlying renal pathology or guide treatment decisions.
An entrepreneur aims for independence and creating wealth through moderate risk-taking and direct involvement in ventures. An intrapreneur also aims for independence and corporate rewards through direct involvement in potentially risky projects, but tries to hide risk until projects have lower risk levels. A traditional manager aims for promotion through careful avoidance of risk, delegates tasks, and usually agrees with upper management. Experience shows that management graduates who later take entrepreneurial roles earn higher incomes than colleagues who remain in traditional management jobs. Entrepreneurs work independently while intrapreneurs work within an organization to provide creativity.
An entrepreneur is defined as an individual who takes on the risk of starting a business or enterprise in an environment of uncertainty. Key elements of entrepreneurship include innovation, risk-taking, vision, and organizational skills. Successful entrepreneurs exhibit traits like innovativeness, willingness to take risks, initiative, perseverance, self-confidence, and leadership. While entrepreneurs are made, not born, becoming an entrepreneur can be triggered by social or economic disruptions and requires the ability to build a team to complement one's own skills.
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This document discusses several anesthetic complications that can occur during pregnancy, including thrombocytopenia/epidural hematoma, aspiration, difficult airways, and neuraxial blockade complications. Key points include: 1) There is no minimum platelet count that absolutely contraindicates neuraxial procedures, but less than 100,000 is often quoted as a threshold. 2) Pregnancy increases the risk of aspiration due to anatomical changes, so all pregnant patients are considered at high risk of aspiration. 3) Airway management can be difficult in pregnancy due to edema and weight gain; facilities should be prepared with multiple airway devices and surgical options. 4) Neuraxial blockade commonly causes hypotension due to sympathetic blockade,
This document provides information on contrast induced nephropathy (CIN), including its definition, pathogenesis, risk factors, incidence, prevention, and management. CIN is a form of acute kidney injury caused by radiocontrast media administration that results in an increase in serum creatinine levels within 3 days. Prevention focuses on hydration, using low- or iso-osmolar contrast agents, avoiding repetitive procedures, and discontinuing nephrotoxic drugs. Treatment is supportive as CIN is generally reversible with hydration and supportive care.
OMEPRAZOLE AND CLOPIDOGREL INTERACTION: CURRENT RECOMMENDATIONSDoc Tony Comia
- Omeprazole reduces the effectiveness of clopidogrel by almost half when taken together due to drug interaction where omeprazole blocks clopidogrel's conversion to its active form.
- Dual antiplatelet therapy with aspirin and clopidogrel is recommended for patients with acute coronary syndromes or stents to reduce risks of cardiovascular events, while a proton pump inhibitor is recommended to reduce risks of gastrointestinal bleeding.
- Recent evidence and meta-analyses suggest the interaction between proton pump inhibitors and clopidogrel does not significantly increase cardiovascular risks for most patients, and no significant differences in risks exist between individual proton pump inhibitors.
This document discusses various drugs used in dentistry, including antibiotics, antifungals, and antivirals. It provides information on the classes, indications, contraindications, side effects and precautions for commonly used medications like penicillin, amoxicillin, metronidazole, fluconazole, acyclovir and valaciclovir. Guidelines are also presented on the appropriate use of antibiotics for conditions like dental infections and the prophylactic use of antibiotics for certain medical conditions undergoing dental procedures.
This document provides an overview of anticoagulants including their mechanisms of action, indications, dosing, and monitoring. It discusses normal hemostasis and coagulation factors. Unfractionated heparin, low molecular weight heparins, and factor Xa inhibitors are described as parenteral anticoagulants. Oral anticoagulants reviewed include warfarin, rivaroxaban, apixaban, and dabigatran. The roles of clinical pharmacists in managing anticoagulation therapy are also mentioned.
This document summarizes the toxicity of oral anticoagulants and related drugs. It discusses how oral anticoagulants like warfarin work by inhibiting vitamin K, which is necessary for blood clotting. It outlines the narrow therapeutic window and need for monitoring with drugs like warfarin. It describes potential toxic effects like bleeding, skin necrosis, and birth defects if taken during pregnancy. Treatment involves investigating coagulation factors, stabilizing the patient, giving vitamin K as an antidote, and supporting bleeding patients with blood products or fresh frozen plasma.
This document provides an overview of enhanced recovery after surgery (ERAS) protocols. It discusses the history and phases of ERAS, including preoperative, intraoperative, and postoperative considerations. Specifically, it outlines strategies to optimize patient nutrition and exercise preoperatively, prevent hypothermia and infections intraoperatively, and promote early mobilization postoperatively. The overall goal of ERAS is to implement a multimodal, evidence-based approach to accelerate patient recovery through the perioperative period.
The document provides a review of therapeutic strategies for acute lung injury and acute respiratory distress syndrome (ARDS) based on published evidence and guidelines. It summarizes definitions of severe ARDS, initial evaluation and interventions including low tidal volume ventilation and conservative fluid management. Further strategies discussed include recruitment maneuvers, high positive end-expiratory pressure, prone positioning, high-frequency oscillatory ventilation, inhaled nitric oxide, glucocorticoids, and extracorporeal life support. Recommendations are provided for each strategy based on risks, benefits, and evidence from clinical trials.
This document discusses principles of antibiotic use in critical care. It notes that up to 50% of antibiotics prescribed are inappropriate and outlines consequences like increased resistance. The key principles for appropriate use are described as using the right antibiotic, at the right time, duration and dose based on the patient's condition and likely pathogens. Factors affecting pharmacokinetics and pharmacodynamics in critical illness are also reviewed to optimize dosing for better outcomes.
This document discusses new-onset diabetes after transplantation (NODAT), which occurs in some patients after receiving a solid organ transplant. It defines NODAT and reviews its epidemiology and risk factors. The document outlines the pathogenesis and risk of NODAT associated with different immunosuppressive drugs. It also discusses the diagnosis, screening, and management of NODAT, including monitoring patients, treating hyperglycemia, and controlling cardiovascular risk factors. The document notes ongoing areas of uncertainty around preventing NODAT and determining the long-term impacts of improved glycemic control.
Dr. Ranjita Acharya discusses perioperative medication management and which medications should be continued or stopped before surgery based on their medical condition. Key points include continuing most cardiovascular medications like beta blockers and antihypertensives to prevent rebound effects, holding diuretics and ACE inhibitors due to surgical risks, and consulting with specialists on anticoagulants and chemotherapy drugs. The presentation provides guidance on cardiovascular, endocrine, neurological, respiratory and gastrointestinal medications to optimize patient safety and surgical outcomes.
Gentamicin is an aminoglycoside antibiotic commonly used to treat early and late onset neonatal sepsis. It is effective against many gram-negative bacteria. Gentamicin is administered intravenously over 30 minutes, with dosage and interval depending on gestational and postnatal age. Therapeutic drug monitoring includes checking peak and trough levels. Adverse effects include nephrotoxicity and ototoxicity. Research is exploring using gentamicin to suppress cystic fibrosis mutations. Gentamicin use in the NICU requires careful monitoring and coordination between the medical team and nursing staff.
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This document summarizes guidelines for empiric antibiotic treatment of lower respiratory tract infections such as community-acquired pneumonia. It recommends using a clinical prediction rule like the Pneumonia Severity Index in addition to clinical judgment to determine whether patients should be treated as outpatients or inpatients. For outpatient treatment of CAP, it recommends amoxicillin, doxycycline, or macrolides depending on patient risk factors and local resistance patterns. For inpatient treatment of non-severe CAP without risk of MRSA or Pseudomonas, it recommends beta-lactam plus macrolide or fluoroquinolone monotherapy. It does not recommend routinely adding anaerobic coverage or extended-spectrum antibiotics without
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Author: Danielle Cassidy, PharmD, BCPS
Audience: Third year pharmacy students at University of Colorado School of Pharmacy & Oregon State University College of Pharmacy.
Background: Provides overview of common causes of pediatric venous thromboembolism & treatment management.
Introduction to pharmaceutical care of geriatric G eriatric pptxmalik1ajlan
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- It is important for clinicians to understand age-related physiological changes like reduced renal function and how those changes impact pharmacokinetics and pharmacodynamics.
- Health care utilization and costs increase substantially with age, as older adults use more services and have longer hospital stays on average. Managing medications can help address issues like polypharmacy and adverse drug events.
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Contrast Simulation Study material 20150509.ppt
1. ACR guidelines on Contrast
Reactions and Management
Z Liu, PGY-3
Boston University Medical Center, Department of Diagnostic Radiology
Last reviewed May 9, 2015
2. Disclaimer
• The information provided herein is designed to aid in the BMC contrast reaction
simulation course and may contain errors.
• All treatments listed herein are for ADULTS.
• DO NOT REFER TO THIS INFORMATION FOR ACTUAL PATIENT CARE
Thank you,
Your Radiology Simulation Team
May 9, 2015
3. INDEX
Abbreviations
1. IV contrast media types
2. Risk factors for contrast reactions
3. Contrast related adverse reactions (CIN, NSF, etc)
4. IV contrast and pregnant patients
5. IV contrast and breast feeding
6. Premedication and BMC regime
7. Acute contrast reactions and management (per ACR guidelines 2013)
8. Reaction rebound prevention
9. MR specific protocol
10. Miscellaneous (translator phone, update allergy on Epic)
References
10. Risk Factors for Adverse Reactions
to Intravenous Contrast Material
History of a prior allergy-like reaction to contrast media is associated with an up
to five fold increased likelihood
Allergic diathesis predisposes individuals to reactions
Asthma may indicate an increased likelihood of a contrast reaction
Anecdotal evidence that severe adverse effects to contrast media or to
procedures can be mitigated at least in part by reducing anxiety
Renal insufficiency: CIN and NSF
11. Other risks
Significant cardiac disease may be a risk factor for contrast reactions.
These include symptomatic patients:
patients with angina or congestive heart failure symptoms with minimal exertion
patients with severe aortic stenosis, primary pulmonary hypertension, or severe but well-
compensated cardiomyopathy.
Limit the volume and osmolality of the contrast media
Paraproteinemias, particularly multiple myeloma, are known to predispose
patients to irreversible renal failure after high-osmolality contrast media (HOCM)
administration due to tubular protein precipitation and aggregation; however,
there is no data predicting risk with the use of low-osmolality or iso-osmolality
agents.
More on risk factors: ACR Manual on Contrast Media Version 9, 2013
12. Thyroid disease and IV contrast
Some patients with hyperthyroidism or other thyroid disease (especially when
present in those who live in iodine-deficient areas) may develop iodine-provoked
delayed hyperthyroidism. This effect may appear 4 to 6 weeks after the IV contrast
administration in some of these patients.
BMC Policy: [Pending policy update]
13. Sickle cell trait or disease
Risk to sickle cell patients from IV administered GBCM at currently approved
dosages must be extremely low, and there is no reason to withhold these agents
from patients with sickle cell disease. However, as in all patients, GBCM should
be administered only when clinically indicated.
14. Metformin
Metformin does not confer an increased risk of CIN. However, metformin can very
rarely lead to lactic acidosis in patients with renal failure. Therefore, patients who
develop CIN while taking metformin are susceptible to the development of lactic
acidosis
BMC policy: [Pending policy update]
15. Neonates and infants
In children, it is prudent to follow the same guidelines that apply to adults.
It should be noted, however, that eGFR values in certain premature infants
and neonates may be < 30 ml/min/1.73 m2 simply due to immature renal
function (and not due to pathologic renal impairment).
In these individuals, the ACR Committee on Drugs and Contrast Media
believes that caution should still be used when administering GBCAs,
although an eGFR value < 30 ml/min/1.73 m2 should not be considered an
absolute contraindication to GBCA administration.
17. Mechanisms of anaphylactoid contrast reactions
~90% of such adverse reactions are associated with direct release of histamine
and other mediators from circulating basophils and eosinophils.
Why use IV methylprednisone?
Reduction in circulating basophils and eosinophils (which reach maximal statistical
significance at the end of 4 hours). A reduction of histamine in sedimented leukocytes
is also noted at 4 hours. Many of these effects reach their maximum at 8 hours.
18. Nephrogenic systemic fibrosis
Fibrosing disease involving skin and subcutaneous tissues, also lungs,
esophagus, heart, skeletal muscles (contractures and joint immobility).
Initial symptoms: skin thickening and or pruritis
BMC policy: [Pending policy update]
19. Delayed reactions to contrast media
Incidence: 0.5 to 14%.
Most commonly cutaneous (urticarial and/or a persistent rash) and may develop
from 30 to 60 minutes to up to one week following contrast material exposure,
with the majority occurring between three hours and two days.
Treatment: supportive, antihistamines and or corticosteroids for cutaneous
symptoms, antipyretics for fever, antiemetics for nausea, and fluid resuscitation
for hypotension.
REMEMBER: Nearly all life-threatening contrast reactions occur within the first 20
minutes after contrast medium injection.
21. Air embolism
• Extremely rare complication
• Power injection minimizes risk
• Air bubbles or air fluid levels in the intrathoracic veins, main PA, or RV.
• Symptoms: air hunger, dyspnea, cough, chest pain, pulmonary edema,
tachycardia, hypotension, or expiratory wheezing. Neurologic deficits may result
from stroke due to decreased cardiac output or paradoxical air embolism.
• Treatment: 100% oxygen and placing the patient in the left lateral decubitus
position (i.e., left side down).
22. Contrast induced nephrotoxicity
• Pathophysiology: unclear but suggested etiologies include renal
hemodynamic changes (vasoconstriction) and direct tubular toxicity
• Absolute increase of Cr of 0.5 mg/dL.
• Risk factors: pre-existing renal insufficiency, acute kidney injury
• Other independent risk factors: diabetes mellitus, dehydration,
cardiovascular disease, diuretic use, advanced age, multiple myeloma,
hypertension, hyperuricemia, and multiple iodinated contrast medium
doses in a short time interval (< 24 hours)
• BMC policy: [Pending policy update]
26. IV contrast media and breast feeding
Plasma half life of IV contrast is ~ 2 hours
Nearly 100% of contrast media is cleared renally within 24 hours given normal
renal function
<1 % is excreted into breast milk in first 24 hours so it is safe for the mother and
infant to continue breast-feeding after receiving such an agent
BMC policy: [Pending policy update]
28. Premedication
No randomized controlled clinical trials have demonstrated premedication
protection against severe life-threatening adverse reactions.
Target premedication to those whom, in the past, have had moderately severe or
severe reactions requiring treatment.
Oral administration of steroids is preferable to IV administration, and prednisone
and methylprednisolone are equally effective. It is preferred that steroids be given
beginning at least 6 hours prior to the injection of contrast media regardless of the
route of steroid administration whenever possible.
BMC policy: Pending policy update
29. BMC Premedication regime
Patients who are able to take medication orally:
Prednisone 50mg tablet by mouth at 13 hours, 7 hours, and 1 hour before injection of
contrast media.
Or
Methylprednisolone (Medrol®) 32mg tablet by mouth at 12 hours and 2 hours before
the injection of contrast media.
Plus
Diphenhydramine (Benadryl®) 50mg intravenously, intramuscularly or by mouth 1 hour
before the injection of contrast media.
30. BMC Premedication regime
Patients unable to take oral medication:
Hydrocortisone: 200mg intravenously at 13 hours, 7 hours, and 1 hour before the
injection of contrast media.
Plus
Diphenhydramine 50mg intravenously or intramuscularly 1 hour before the injection of
contrast media.
31. BMC Premedication regime
Emergent or Urgent patients:
Dexamathasone (Decadron) 4-8 mg intravenously.
Plus
Diphenhydramine (Benadryl®) 25mg intravenously.
Wait 15 minutes and scan.
33. Assessing for potential contrast reaction
How does the patient look?
Can the patient speak? How does the patient’s voice sound?
How is the patient’s breathing?
What is the patient’s pulse strength and rate?
What is the patient’s blood pressure?
34. Acute adverse reactions
• May be allergic-like (not true allergy, often idiosyncratic and may differ
immunologically from true allergies despite similar clinical presentations) or
physiologic (a physiologic response to contrast material).
• Mild
• Moderate
• Severe
35. Allergy
Anaphylaxis
Severe
Rapid onset
IgE mediated (prior sensitization)
Non dose dependent
Anaphylactoid
Less severe
Slower onset
Mast cell cascade (NOT IgE)
Dose dependent
41. HIVES-GENERAL
Observe patient until hives are resolving.
Further observation may be necessary if treatment is administered.
BMC policy: [Pending policy update]
42. HIVES-MILD
*Note: All forms can cause drowsiness; IV/IM form may cause or worsen hypotension.
** Note: second generation antihistamines cause less drowsiness; may be beneficial in patients that need to drive themselves home.
43. HIVES-MODERATE
*Note: All forms can cause drowsiness; IV/IM form may cause or worsen hypotension.
** Note: second generation antihistamines cause less drowsiness; may be beneficial in patients that need to drive themselves home.
45. DIFFUSE ERYTHEMA
Preserve IV access
Monitor vitals
Pulse ox
Give O2 by mask (6-10L/min) in all patients
If normotensive: no additional treatment
46. DIFFUSE ERYTHEMA-HYPOTENSIVE
* Note: in hypotensive patients, the preferred route of epinephrine delivery is IV, as the extremities may not be perfused sufficiently to
allow for adequate absorption of IM administered drug
47. Bronchospasm
• Preserve IV access
• Monitor vitals
• Pulse ox
• Give O2 by mask (6-10L/min) in all patients
53. Hypotension
Systolic BP < 90 mm Hg
Two forms:
Hypotension with bradycardia
Hypotension with tachycardia
54. Hypotension
Preserve IV access
Monitor vitals
Pulse ox
Give O2 by mask (6-10L/min) in all patients
Elevate legs at least 60 degrees
Consider IV fluids: 0.9% Normal Saline or Latcted Ringers, 1,000 mL rapidly
57. UNRESPONSIVE AND PULSELESS
• Apply BLS, ACLS
• Activate emergency response team
• If at Menino or ENC, call 4-7777
• If at Shapiro, call public safety 4-4444 (they will call 911)
58. HYPERTENSIVE CRISIS
BP>200/120, SYMPTOMS OF END ORGAN COMPROMISE
•Preserve IV access
•Monitor vitals
•Pulse ox
•Give O2 by mask (6-10L/min) in all patients
•Labetalol (IV): 20 mg IV slowly over 2 min
OR
•Nitroglycerine tablet (SL): 0.4 mg tablet; can repeat every 5–10 min
•Furosemide (lasix): 20-40 mg IV slowly over 2 min
59. PULMONARY EDEMA
• Activate emergency response team
(4-7777 at Menino or ENC; 4-4444 at Shapiro (public safety will
call 911)
• Preserve IV access
• Monitor vitals
• Pulse ox
• Give O2 by mask (6-10L/min) in all patients
• Elevate head of bed, if possible
• Furosemide (lasix): 20-40 mg IV slowly over 2 min
• Morphine (IV): 1-3 mg, repeat every 5-10 min as needed
60. SEIZURES/CONVULSIONS
Observe and protect the patient (turn patient on side to avoid aspiration)
Suction airway, as needed
Preserve IV access
Monitor vitals
Pulse oximeter
O2 by mask (6-10 L/min)
If unremitting:
Call a code or 911
Give Lorazepam* (IV) IV 2–4 mg IV; administer slowly, to maximum dose of 4 mg
*Ativan®
61. Observation period
In those patients whose allergic reaction is not severe and can be monitored in
the recovery area, ACR guideline recommends observing the patient until
patient’s symptoms completely resolve
BMC protocol: Observe for 30 minutes or until symptoms resolve.
Give patients clear instructions to seek additional medical care, should there be
any worsening of symptoms, skin ulceration, or development of any neurologic or
circulatory symptoms including paresthesias.
63. MR specific protocol
Leave all metal objects at Zone II or III including cell phones, credit cards, etc.
Must first transfer patient (in Zone IV) to Zone II (outside magnet area) on MRI
compatible stretcher before any further assessment and treatment.
Zone I: All areas freely accessible to the general public without supervision.
Magnetic fringe fields in this area are less than 5 Gauss (0.5 mT).
Zone II: Still a public area, but the interface between unregulated Zone I and the
strictly controlled Zones III and IV. MR safety screening typically occurs here.
Zone III: An area near the magnet room where the fringe, gradient, or RF magnetic
fields are sufficiently strong to present a physical hazard to unscreened patients
and personnel.
Zone IV: Synonymous with the MR magnet room itself.
65. How to call a code
At Menino and ENC: 4-7777
At Shapiro: Call 4-4444 (public safety will call 911)
Know relevant information when calling a code (Name, adult vs child, location,
type of contrast event, what happened, any pertinent medical history).
66. How to use the translator phone
If using the blue phone-press on the pre-programmed blue button or dial 7-8787
to get a translator. Will ask for language, department you are calling from, and
patient’s MRN.
If using a white phone, dial 7-6767. Follow the same steps as above.
If using a red phone (in house translator), directly asks for an available in house
translator (might have to wait).
67. Updating allergic reaction on Epic
Click on the allergies tab on the left hand side, click on add a new agent, a
drop down menu will appear and you can add the new agent and the
associated reactions.
New contrast allergies can be updated by contacting CT manager Christine
Seay.
68. References
ACR Manual on contrast media 2013 version 9
BMC Adverse reactions to contrast media and contrast extravasations
BMC recommendation for serum creatinine for contrast administration
BMC Guidelines for management of acute contrast reactions in adults
BMC Contrast media allergy prophylactic medication regimens
BMC contrast media and the pregnant patient
Singh J, Daftary A. Iodinated contrast media and their adverse reactions. J Nucl Med Technol.
2008 Jun;36(2):69-74; quiz 76-7. doi: 10.2967/jnmt.107.047621. Epub 2008 May 15. Review.
PubMed PMID: 18483141.
http://mri-q.com/acr-safety-zones.html
Back to Index
Editor's Notes
Remove ACR guidelines
This incorporates ACR guidelines.
Highlight take home points
FDA categories??
Add BMC policy: Do give iodinated, no Gd
Define hypertensive urgency: severe elevation of BP without progressive target organ dysfunction. VS. Hypertensive emergency: BP > 180/120 mm Hg with impending or progressive target organ dysfunction (Examples: coronary ischemia, disordered cerebral function, CVA, pulmonary edema, and renal failure). Ref: Hospital physician March 2007 (Hypertensive urgency and emergency).