Radio-imaging contrast- allergy and nephropathy

steroid prophylaxis for patients at risk of contrast reactions:

PO pred 30mg 12 hrs and 2 hrs before

if urgent: as soon as scan confirmed : IV hydrocortisone 200mg
IV benadryl 50mg (slow bolus or IM or PO)- not faster than 25mg/min

contrast nephropathy : PO acetylcysteine: bioavailability of glutathione higher. STart 600mg BD on day before until day after scan.
If scan decided stat: IV acetylcysteine
bolus 150mg/kg in 500ml NS 30-60min before scan then 50mg/kg in 500ml over 4hours after scan

IV risk of hypersensitivity

ENIGMA I

2050 patients,
non cardiac surgery >2 hrs with or without nitrous

followed up max 5.7 years (median 3.5)
primary end point= survival

a/w long term AMI risk but not death or stroke

need further RCT

novoseven Control trial

Results of the CONTROL Trial: Efficacy and Safety of Recombinant Activated Factor VII in the Management of Refractory Traumatic Hemorrhage

C Hauser et al. J Trauma. Sept 2010: 69(3); 489-500

481 blunt and 92 penetrating) who bled 4 to 8 red blood cell (RBC) units Patients were assigned to rFVIIa (200 μg/kg initially; 100 μg/kg at 1 hour and 3 hours

Results: Enrollment was terminated at 573 of 1502 planned patients because of unexpected low mortality prompted by futility analysis (10.8% vs. 27.5% planned/predicted) and difficulties consenting and enrolling sicker patients. Mortality was 11.0% (rFVIIa) versus 10.7% (placebo) (p = 0.93, blunt) and 18.2% (rFVIIa) versus 13.2% (placebo) (p = 0.40, penetrating). Blunt trauma rFVIIa patients received (mean ± SD) 7.8 ± 10.6 RBC units and 19.0 ± 27.1 total allogeneic units through 48 hours, and placebo patients received 9.1 ± 11.3 RBC units (p = 0.04) and 23.5 ± 28.0 total allogeneic units (p = 0.04). Thrombotic adverse events were similar across study cohorts.

Conclusions: rFVIIa reduced blood product use but did not affect mortality compared with placebo. Modern evidence-based trauma lowers mortality, paradoxically making outcomes studies increasingly difficult.

trauma novoseven

http://www.trauma.org/index.php/main/article/367/print

drugs for pregnant

http://www.scribd.com/doc/33591624/Prescribing-Medicine-in-Pregnancy-By-Australian-Drug-Evaluation-Committee

by 'australian drug evaluation committee' now advisory committee on prescription meds'

intralipid/ lipid rescue

use in LA toxicity with cardiac arrest especially bupivacaine (CC:CNS ratio?)
functions as a 'lipid sink' for lipophilic agents


resus according to BCLS protocols-lipid rescue-post op icu monitoring

Contents:
Purified soybean oil 200 g
Purified egg phospholipids 12 g
Glycerol anhydrous 22 g
Water for injection q.s. ad 1000 mL
pH is adjusted with sodium hydroxide to approximately pH 8.
Energy content/L: 8.4 MJ (2 000 kcal).
Osmolality (approx.): 350 mOsm/kg water. 500ml bottle: first 100ml over 15 min then 400ml over

protocol:.5ml/kg as initial bolus, then 0.25ml/kg/min for 30-60 mins
In actual resuscitation for a 70kg person: 100ml as bolus then 400ml over the next 15mins

http://www.lipidrescue.org/

TIVA for spine op

anterior cervical discectomy and fusion for 2 levels with neurophysio monitoring

85kg young man

supine, arms tucked in, long extensions, warmer, BIS
induction as per normal ( armoured tube minus stylet, rocuronium and fentanyl)
armoured tube: NG for op, bite block, IDC. op about 3-4 hours
TIVA propofol bristol model 10-8-6 maintained at about 5-6mg/kg/hr (about 510mg/hr!!)
BIS 40-55
morphine 6mg at the end
*no nitrous or benzos but used remifentanyl 0.1mcg/kg/min
post op cervical collar

ps. usually no MEP/SSEP monitoring

bristol model

propofol 10-8-6mg/kg/HOUR
10mg/kg/h for 10 min, 8mg/kg/h for 10 min, 6mg/kg/h
note: n20 used