Emergency medicine pharmd april 2013 nanoxia coolforce

• the final concentration of factor IX per vial upon recons titution ranges from 20 to 31 units/ml .

• kcentra has currently been approved in the united S tates for the reversal of life-threatening hemorrhage se conda ry to warfarin.

• the weight-based dosing reg imen of kcentra is based on t he in itial INR. T he dose is ma ximized as follows in patients weigh ing great er than 100 kg:

• INR of 2 to les s than 4: 25 unit s/kg (maximum dose: 2500 unit s)

• INR of 4 to 6: 35 unit s/kg (maxi mum dose: 3500 units)

• INR of greater than 6: 50 units/kg (maxi mum dose: 5000 unit s)

• the manufa cturer does not recommend re-dosing kcentra, as this has not been evaluated in clinical trials.


• vitamin K (ph ytonadione) should be admin istered along with kcentra to s ustain the levels of vitamin K-dependent clotting factor s.Nanoxia coolforce

• the recommended rate of administration of kcentra is 0.12 ml/kg/min ( approximat ely 3 units/kg/min), up to a maximum rate of 8.4 ml/min (210 units/min) via IV infusion.

• in terms of st orage and shelf life:

• should be store d at temperatures between 2 and 25°C (36 to 77°F).

• stable for 36 months from the date of manufacture, up to the expiration date on the packaging of the product.

• after reconstitution, the product is stable for 4 hours.

• as could be expected, adverse e vents associated with the use of kcentra include thromboem b olic complications ; those reported from the clinical trials include myoc ardial in farction, deep vein thromb o sis, and cerebrovascular accidents.

• other common adver se events that patients experienced in the clinical trials of kcentra include arthralgia (3.9 %), head a che (7.8 %), hypotensio n (4.9%), and nausea and vomiting (3.9%).Nanoxia coolforce

• the cl inical trials of kcentra excluded those patients w ith a history of thromboembolic events occurring within the previous three months ; use of kcentra is not recommended in this patient population.

Stay tu ne d for future posts rega rding kcentra, including a review of the clinic al trials a s well as the incorporation of the product into our practice.

Reference:

Nicardipine would seem logical as an alternative to

Nimodipine. From the same class of CCB, similar pharmacokinetics and the

Availability of an IV dosage form in the US.

However, the clinical, randomized data has not shown an improvement in

Neurological outcome in SAH patients. In a randomized-placebo controlled trial

Conducted in the early 1990’s, nicardipine reduced the incidence of symptomatic

nanoxia coolforce

Vasospasm vs placebo. 2 at three months, there was no difference in

GOS and NIHSS. While this study didn’t

Show an overall benefit for nicardipine, it is important to note that the study

Was stopped early and therefore underpowered, because nimodipine became

Commercially available in the USA during enrollment. The resulting power of the

Study was not the original 0.9, but 0.7. In addition, fewer patients in the

Nicardipine arm received adjuvant therapy for symptomatic vasospasm vs placebo,

Potentially reflecting under-treatment of those patients. What I walk away with from this study is that

Nicardipine 1) does not worsen outcomes vs placebo and 2) has not been adequately

Studied to say there is no benefit.Nanoxia coolforce at worse, it is certainly an option if

Nimodipine is not available. A follow up study was published, but only compared

High vs low dose nicardipine, with no placebo (or nimodipine) arm. 3

Enter cocaethylene…And it is far from the coca-cola produced during your great grandmother’s time.

Cocaethylene (also known as ethylbenzoylecgonine) is produced from the concomitant ingestion of cocaine and alcohol. It is formed by the liver through a transesterification reaction of cocaine that occurs in the presence of ethanol through the activity of the nonspecific enzyme, cocaine carboxylesterase.

Like cocaine, cocaethylene blocks the reuptake of dopamine in the central nervous system and increases the extracellular concentration of dopamine in the accumbens nucleus, which produces euphoria and other similar effects.Nanoxia coolforce this effect may potentiate the toxicity of cocaine. However, cocaethylene has very little activity on the serotonergic system. In addition, the half-life of cocaethylene is longer than that of cocaine (nearly 2 hours for cocaethylene, compared to 40 minutes for cocaine), which can lead to prolonged toxicity. In addition, the LD 50 of cocaethylene is lower than that of cocaine, which can be of potential

Concern in the patient who presents with concomitant ingestion of

Cocaine and alcohol.

The order of ingestion is important here, as the ingestion of ethanol preceding the ingestion of cocaine will not only lead to the formation of cocaethylene, but will also increase the plasma levels of cocaine and lead to a prolonged euphoric effect.Nanoxia coolforce

In terms of manifestations of toxicity, animal models have demonstrated that cocaethylene has myocardial depression effects and can decrease stroke volume, contractility, and mean arterial pressure. In addition, it has also been shown to increase the incidence of EKG abnormalities and lead to life-threatening dysrhythmias in a dose-dependent manner as a result of its greater potent effects on sodium channel blockade. It has also been shown to have inhibitory properties on the potassium and calcium channels in the heart, and one case report has described a patient who experienced qtc prolongation and torsades de pointes as a result of a dual ingestion of cocaine and ethanol.

It is difficult to extrapolate the effects that cocaethylene has demonstrated in animal studies to human patients, but it is important to be mindful of the effects of the combination of cocaine and alcohol and the potential for the formation of cocaethylene in the setting of such a dual ingestion.Nanoxia coolforce

References:

Jatlow P. Cocaethylene: pharmacologic activity and clinical significance. Ther drug monit 1993; 15:533-536. [PMID: 8122289]

Andrews P. Cocaethylene toxicity. J addict dis 1997; 16:75-84. [PMID: 9243342]

Hearn WL, rose S, wagner J, et al. Cocaethylene is more potent than cocaine in mediating lethality. Pharmacol biochem behav 1991; 39:531-533. [PMID: 1946594]

Wilson LD, french S. Cocaethylene’s effects on coronary artery blood flow and cardiac function in a canine model. J toxicol clin toxicol 2002; 40:535-546. [PMID: 12215047]

Wilson LD, henning RJ, suttheimer C, et al. Cocaethylene causes dose-dependent reductions in cardiac function in anesthetized dogs. J cardiovasc pharm 1995;26:965-973. [PMID: 8606535]

nanoxia coolforce

Wilson LD, jeromin J, garvey L, et al. Cocaine, ethanol, and cocaethylene cardiotoxicity in an animal model of cocaine and ethanol abuse. Acad emerg med 2001;8:211-222. [PMID: 11229942]

Xu YQ, crumb WJ, clarkson CW. Cocaethylene, a metabolite of cocaine and ethanol, is a potent blocker of cardiac sodium channels. J pharmacol exp ther 1994; 271:319-325. [PMID: 7965731]

While compounding instructions exist on other sites, I have

My own method. I’ve adapted to the method describe below as a result of poor

Response during my initial experience with push dose pressors, even at

Relatively high doses of phenylephrine. I

Started to become concerned that the final concentration of phenylephrine in

The syringe was not what was desired since I was mixing 1ml into a 100ml bag of

nanoxia coolforce

NS. Additionally, it is not widely known

Outside the walls of the pharmacy that commercially available IV piggyback bags

Contain various amounts of overfill. For example, in a 100ml NS contains

Approx. 109mL. So adding 1ml will make the total volume 110ml and therefore, a

More dilute final concentration. In pharmacy there is a general rule that

Unless you are adding 10% of the volume of the bag, you do not need to

Account for over fill. In this instance, however, since you’re withdrawing a

Small amount from the bag, which is highly dependent on the final

Concentration, the overfill must be taken into consideration.

Very few case reports and small anecdotal studies describe the use of intracardiac epinephrine in the setting of emergent thoracotomy in traumatic cardiac arrest.Nanoxia coolforce

Here are some pointers to remember regarding this technique for administration:

• the dose is the same dose that is used in the guidelines for advanced cardiovascular life support (ACLS): 1 mg.

• use whatever epinephrine product you have available, whether it be the 1:10,000 (1 mg/10 ml) or 1:1,000 (1 mg/ml) concentration; both concentrations have been studied and are acceptable for use.

• in terms of needle size and length:

• the best bet to use is an 18-gauge or 22-gauge needle; anything smaller than this is generally not recommended due to the potential for vascular injury to the cardiac tissue.

• A 1.5-inch needle should be sufficient. Interestingly enough, a number of pharmaceutical companies have manufactured epinephrine specifically for intracardiac injection, which is available in a pre-filled syringe with a 3.5-inch needle attached (fancy, but can create trauma drama and probably not truly necessary).Nanoxia coolforce

• cardiac compressions should be discontinued temporarily while intracardiac administration occurs to prevent injury to the person performing chest compressions.

• the epinephrine should be administered as rapid push and directly injected into the chamber of the left ventricle while cardiac massage is ongoing. This can be achieved by lifting the heart outwards to allow for easier visualization of the left ventricle.

• chest compressions can be resumed once the dose has been administered.

• the dose of intracardiac epinephrine of 1 mg can be repeated every 3 to 5 minutes, as per the ACLS algorithm.

Some complications that patients may experience include ventricular and coronary artery laceration, pneumothorax, and cardiac tamponade.Nanoxia coolforce because of this, an organized method is necessary for this technique in order to ensure appropriate administration.

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• fast facts about kcentra, the new four-factor PC…

• kcentra, octaplex, USA 4-factor pccs

• nimodipine shortage: what about nicardipine

• cocaethylene: not your old coca-cola

• push-dose phenylephrine: experience and important …

• the trauma cupid’s arrow: intracardiac epinephrine…

• digoxin, potassium and calcium

• cold lysis: alteplase in the hypothermic patient

• sports pharmacy

• A closer look at glucagon for the foreign body

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