Job Aid Faktor Injeksi Kontras dan Waktu Scan

SIEMENS Healthineers .. Contrast Media Contrast Administration and Injection Strategy Restricted © Siemens Healthcare GmbH, 2017 Our Discussion SIEMENS Healthineers .. BRACCO Contrast Enhancement lopamiro Factors 370 Non-ionic, water soluble Prediction of Scan contrast medium Timing lopamidol lopamiro One bottle of 50 ml 370 used immedos Injection Strategy package Brocco spa 18.5 g of lodine Restricted © Siemens Healthcare GmbH, 2017 SIEMENS Healthineers .. Contrast Enhancement Factor Injection Factors, Patient Factors, Scanner Factors Click to add footnote 3 second line Restricted © Siemens Healthcare GmbH, 2018 Contrast Enhancement Factors SIEMENS Healthineers Patient Factors Scanner •Patient Body Weight Factors •Cardiac Output Contrast Media Factors •Injection (Flowrate, Volume, Duration) Patient’s •Concentration Factors Scanner Factors Contrast •Exposure Factors Medium Factors 4 Restricted © Siemens Healthcare GmbH, 2018 Patient’s Factors ; Body Weight SIEMENS Healthineers • Higher body weight resulting more vascular and 110 lbs 480 blood amount -x- 150 lbs 400 -O- 200 lbs • Additional Contrast Volume may required 100 250 lbs 1:40 • Lower enhancement of contrast media 200 130 Time (min) a 5 Restricted © Siemens Healthcare GmbH, 2018 Patient Factor in Contrast Enhancement (Body Weight) SIEMENS Healthineers .. Volume of contrast Degree of enhancement 6 Restricted © Siemens Healthcare GmbH, 2018 Patient’s Factors ; Cardiac Output SIEMENS Healthineers 450 Cardiac output depend on age, physical activity 400 60% Reduction • 350 +40% Reduction and gender -- 20% Reduction 300 - Baseline CO 250 • Higher cardiac output resulting shorter contrast 200 arrival time 150 • Lower cardiac output may lead higher contrast 100 Aortic Enhancement (HU) enhancement 50 0 0 15 30 45 60 75 90 105 120 135 150 165 180 Time after the start of injection (sec) 7 Restricted © Siemens Healthcare GmbH, 2018 Contrast Enhancement ; Contrast Concentration SIEMENS Healthineers .. 400 350 -400 mgl/mL 300 -350 mgl/mL 250 -300 mgl/mL 0.1 1.0 10 100 mg/ml mg/ml mg/ml mg/ml 200 150 100 14 HU 24 HU 305 HU 2679 HU 50 Aortic Enhancement (HU) 0 0 15 30 45 60 75 90 105 120 Time after the start of injection (sec) 8 Restricted © Siemens Healthcare GmbH, 2018 Contrast Enhancement ; Injection Rate/ Flowrate SIEMENS Healthineers .. 350 *- 5 mL/s • Higher Flowrate Increase Arterial 300 -63 mL/s Enhancement 250 -+1mL/s • 200 Reducing Injection Duration 150 • High Flowrate Requires Appropriate IV 100 Access 50 Lead Venous Reflux Aortic Enhancement (HU) • 0 0 15 30 45 60 75 90 105 120 135 150 165 180 Time after the start of injection (sec) 9 Restricted © Siemens Healthcare GmbH, 2018 Contrast Enhancement ; Contrast Duration and Volume SIEMENS Healthineers .. 300 DOE +175 mL *175 mL 250 -125 mL 250 125 mL 200 * 75ml 200 *75 ml 150 150 100 100 Aortic Enhancement (HU) Hepatic Enhancement (HU) 50 50 0 0 0 15 30 45 60 75 90 105 120 135 150 165 180 0 15 30 45 60 75 90 105 120 135 150 165 180 Time after the start of injection (sec) Time after the start of injection (sec) Increasing injection duration lead higher enhancement, but it will cause prolongation of peak enhancement. 10 Restricted © Siemens Healthcare GmbH, 2018 Contrast Charecteristics ; K- edge binding energy SIEMENS Healthineers .. • Iodine K-Edge = 33,20 keV - lodine - Soft tissue (ICRU-44) • Energy closer to this K-Edge will 40 35 experience heavier attenuation 30 • 80 kVp (± 43 KeV) will result in higher 25 20 80 kVp contrast enhancement compare to 120 15 10 - 120 kVp kVp (± 70 KeV) 5 - 80 O 40 60 100 120 140 160 Mass attenuation coefficient (cm2/g) Lower kVP à Increased image noise • Photon energy (kev) 11 Restricted © Siemens Healthcare GmbH, 2018 Scanner Factors ; kilo Voltage SIEMENS Healthineers .. 700 y = 41.12x 600 R2 = 0.999 80 kVp 500 D 100 kVp y = 31.74x R2 = 0.998 120 kVp 400 300 y = 26.18x R = 0.999 200 a. 80 kVp b. 140 kVp Contrast Enhancement (HU) 100 Courtney A. Course, MD, et. Al. , Dual energy multidetector CT : How Does It Work, What Can It Tell Us, and When Can We Use It in Abdominopelvic Imaging? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 lodine Concentration (mgl/mL) 12 Restricted © Siemens Healthcare GmbH, 2018 SIEMENS Healthineers .. Fixed Delay, Bolus Tracking, Test Bolus Prediction of Scan Timing ---- ------ Click to add footnote 13 second line Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing SIEMENS Healthineers .. Fixed Delay Test Bolus CARE Bolus/ Tracking 14 Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing SIEMENS Healthineers .. T. peak Scan Scan Delay Scan Duration Duration Contrast Medium Arrival Not that easy Time FERGUSO!! Contrast Medium 1 Injection Duration Scan Delay = ࢑ࢇࢋ࢖ࢀ− Scan Duration 2 15 Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing ; Fixed Delay SIEMENS Healthineers .. 450 Scan 400 60% Reduction Duration 350 40% Reduction -e- 20% Reduction 300 - Baseline CO 250 Contrast 200 Medium 150 Arrival Time 100 Aortic Enhancement (HU) 50 Contrast Medium Cardiac Output O Injection Duration 0 15 30 45 60 75 90 105 120 135 150 165 180 Time after the start of injection (sec) 16 Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing ; Fixed Delay SIEMENS Healthineers .. Injection duration Scan Duration Pulmonary Aorta Peripheral run-off Artery Contrast Medium Enhancement Arrival Liver Time Time Contrast Medium Injection Duration scan delay Arrival Time and duration 17 Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing ; Fixed Delay SIEMENS Healthineers .. T. peak Scan Delay Scan Duration Scan Duration Injection Duration Additional Delay Contrast Medium Arrival Time Scan Delaybrain = ID + 8 - G × (ࡰࡿ Contrast Medium Injection Duration Scan Delayneck = ࡰࡵ૚) + ૞ − 2 × (ࡰࡿ Scan Delaybody = ࡰࡵ૚) + ૙૚ × (ࡰࡿ − ID = Injection Duration SD = Scanning Duration 18 Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing ; Fixed Delay SIEMENS Healthineers .. Jugular Vein Sagital sinus Cerebral (30 – 50s) (20 – 40s) (20 – 22s) Antecubital vein ( 0 Carotid (15 – 20 s) s) PA (10 – 12s) SVC ( 3 - 5 s) / (50 – 60 s) Aorta (15 – 45s) Portal Venous Heart (45 – 80s) Femoral artery Femoral Venous (50 (40 – 50s) 120 s) – Lower Limb Lower Limb (50 – 70s) (70 – 90 s) IVC (70 – 150s) 19 Kyongtae.T Bae ; Intravenous Contrast Medium Administration and Scan Timing at CT: Considerations and Approaches Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing ; Test Bolus SIEMENS Healthineers .. Methods for predicting Scan Timing/ Delay by injecting small amount of contrast media, and measure the arrival time at the anatomical target Results must be calculated with special software (DynEva) Some Consideration : • Test Bolus target may be variable • Test Bolus Injection and Main Injection flowrate should be same • Contrast Volume for Test Bolus 5 – 10 ml, and followed by saline 50 ml. • Dual Syringe injector is mandatory Advantages Disadvantages • Patient Comfort • Less Contrast Efficiency Enhancement Control/Peak Calculation in Multiple Target • • Cumbersome and need more time • Provide more Accuracy 20 Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing ; Test Bolus SIEMENS Healthineers Patient Applications Edit View Image Scroll Options System Help Examination Liew Kim Kooi A HTAA KUANTAN CT14-0932 Liew Kim Kooi HOSPITAL TENGKU AMPUA SAS071000 Ref.: Klinik Kardio SAS071000 Ref.: Klinik Kardio *22-Apr-1954, M, 59Y SOMATOM Definition Flash *22-Apr-1954, M, 59Y SOMATOM Definition Flash Liew Kim Kooi # 0601IUM000134150 F-SP-CR # 0601IUM000134150 F-SP-CR 19-Mar-2014 19-Mar-2014 12:47:47.61 12:47:39.64 Draw ROI 3 IMA 5 IMA 1 SEQ 7 MIP SP -1208.0 SP -1208.0 Viewing R R Rep 0 Tissue Classification Upper Limit [HU] 3071 Filming Lower Limit [HU] Test Bolus Delay kV 100 kV 100 -1024 MAS 30 SL 10.0/1x10.0 B40f S3TO 1eva 562 350 SL 10.0 50 DynEva MIP Delay from start 10.0 - Liew Kim Kooi HOSPITAL TENGKU AMPUAN AFZAN Liew Kim Kooi HOSPITAL TENGKU AMPUAN AFZAN of injection [s] SAS071000 Ref.: Klinik Kardio SAS071000 Ref.: Klinik Kardio *22-Apr-1954, M, 59Y SOMATOM Definition Flash *22-Apr-1954, M, 59Y SOMATOM Definition Flash # 0601IUM000134150 F-SP-CR # 0601IUM000134150 CT 2012B 19-Mar-2014 20-Mar-2014 12:47:39.64 19:04:26.38 ROI | Peak [HU] Time To Peak [s] Sample [HU] at 17.97 s IMA O 1 124.5 18.0 DYB 124.5 SP -1208.0 Mean [HU] DynEva 130 116 R 102 88 74 60 46 32 18 KV 100 -10- End Evaluation Time [s] SL 10.0 2.2 4.4 6.6 8.8 11.0 13.3 15.5 17.7 19.9 22.1 DynEva Baseline 0.0 DynEva Relative Enhancement Curves Draw ROI mode Results stored. 20-Mar-2014 19:05:02 21 Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing ; Test Bolus SIEMENS Healthineers ew Kim Kooi HOSPITAL TENGKU AMPUAN AFZAN .5071000 Ref.: Klinik Kardio 2-Apr-1954, M, 59Y SOMATOM Definition Flash 160IIUM000134150 -Mar-2014 CT 20128 Time To Peak [s] :04:26.38 ROI Peak [HU] "ime To Peak [s] Sample [HU] at 17.97 s 1 124.5 18.0 18.0 Mean [HU] 130 116 102 88 74 60 46 32 18 4 -10 Time [s] 0.0 2.2 4.4 6.6 8.8 11.0 13.3 15.5 17.7 19.9 22. DynEva Relative Enhancement Curves stored. 22 Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing ; Test Bolus SIEMENS Healthineers SL 3.0/64x0.6/p0.2 350 155 -37/0 50 B31s L35H0 K2 66 bpm, .................. 01_CoronaryCTA_RSPS (Adult) SUJENAL, TN CaScore i Eff. MAS 211 CARE Dose4D Insert TTP Pause 110 CTDIvol 15.55 Calculation into CaScore Scan time |10.12 s RT Delay of CT Delay 13 s Angiography Contrast k Slice 3.0 mm Acq. 64 TestBolus 3 Contrast Tilt 0.0 . Delete unsuitable scans Comments CorCTABi 4 Range: Begin End Tab Hold -1092.6- -976.1 Recon Recon Routine Scan 23 Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing ; Test Bolus SIEMENS Healthineers .. T. peak Delta Peak Enhancement 1 Scan Delay 2 Main Injection Duration – Test Bolus Injection Duration 7 Scan Duration T.peak = Peak Enhancement in main injection TB.peak = Peak Enhancement in test bolus (TTPDynEva) TB. peak *) Peak Enhancement happened in the middle of contrast injection Delta Peak Enhancement ࢔ࢇࢉࡿ ࢟ࢇ࢒ࢋࡰ ࢑ࢇࢋ࢖࡮ࢀ + ࢇ࢚࢒ࢋࡰ) ࢑ࢇࢋࡼ ࢚࢔ࢋ࢓ࢋࢉ࢔ࢇࢎ࢔ࡱ (࢔࢕࢏࢚ࢇ࢛࢘ࡰ = ࢔ࢇࢉࡿ − NIH 24 Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing ; Test Bolus SIEMENS Healthineers .. T. peak Injection Test Bolus : 10 ml with Flowrate 5ml/sec Test Bolus Injection Duration = 1 sec Scan Delay Scan Duration Main Injection : 50 ml with Flowrate 5ml/sec 1 Main Injection Duration = 2 5sec Delta Peak Enhancement = 5 – 1 = 4 Sec TB. peak Scan Duration = 4 Sec Delta Peak Enhancement Scan Delay = TBpeak + (4 - .4) 1 2 25 Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing ; Bolus Tracking/ CARE Bolus SIEMENS Healthineers .. Triggered Scan by ROI Threshold in Particular Object or Anatomy Technique and Modification : • Automatic Scanning with 50 – 150 HU Trigger at Arcus Aorta • Eyeballing Technique by Placing ROI outside scanned object or Turn off Automatic Scanning Single Injection Technique -> Contrast Efficiency Contrast 175 ml 0 ml M Director coupled istert buttonk Saline 188 m 0 ml OUNEBEI PTUIOCO E [HU] 200 160 auto 120 80 100 40 0 T 0 10 20 30 40 50 60 t [s] Routine Baling Scan Recon Auto Tasking Trigger Contrast 26 Restricted © Siemens Healthcare GmbH, 2018 Prediction of Scan Timing ; Bolus Tracking/ CARE Bolus SIEMENS Healthineers .. Peak enhancement 350 Scan Delay = ࢑ࢇࢋ࢖ࢀ− Scan Duration NIA 300 250 Scan delay 200 - = Peak time -(1/2) Scan duration Scan duration Scan Delay = ࢘࢘ࢇࢀ + Diagnostics Delay 150 4 Trigger time = Additional contrast arrival : (diagnostic) delay *) Commonly used Diagnostics Delay = 2 - 3 second Aortic CE (HU) 100 (Tarr) *) For minimum Venous Appearance, maintain 50++ Bolus-tracking threshold *) Diagnostics delay, may depend on Patient Instruction *) Scanner Limitation provide minimum 2 – 5 sec 10 20 30 40 50 + ---- Injection duration Time after start of injection (sec) 27 Restricted © Siemens Healthcare GmbH, 2018 SIEMENS Healthineers .. Volume and Flowrate Contrast Injection Strategy Click to add footnote 28 second line Restricted © Siemens Healthcare GmbH, 2018 Contrast Volume Calculation SIEMENS Healthineers .. Calculating contrast volume : (Recomended Dose (gI/Kg) * Body weight) (Concentration / 1000) Example : * With 120 kV scan Patient Weight = 60 Kg Examination Recommended Iodine Contrast concentration : 370 mgI/ml Dose Desired Iodine Dose : 0.27 mgI/ kg Liver 0.5 gI/kg Contrast Volume needed ? Body Angio 0.34 gI/ kg 0.27 gI/kg * 60 kg 16.2 gI = 44 ml Brain CTA 0.27 gI/kg = (370 mgI/ml / 1000) 0.37 Brain Parenchim 0.3 – 0.4 gI/kg Neck Soft Tissue 0.4 gI/kg 29 Intravenous Contrast Medium Administration and Scan Timing at CT ; Kyongtae T Bae Restricted © Siemens Healthcare GmbH, 2018 Contrast Volume Calculation SIEMENS Healthineers .. Calculating contrast volume : (12,753 gI/m2 ) * BSA) (Concentration / 1000) * With 120 kV scan Example : Patient Weight 80 kg, Height 170 cm, BSA = 1.9437 Contrast concentration : 370 mgI/ml Desired Iodine Dose : 270 mgI/ kg .. Contrast Volume needed ? 12,753 gI/m2 * 1,9437 24,788 gI 66 ml = = (370 mgI/ml /1000) 0.37 30 Restricted © Siemens Healthcare GmbH, 2018 Contrast Volume Calculation SIEMENS Healthineers .. Reducing contrast media volume : reference kV -> new kV % Example 2 : Patient Weight = 70 Kg 120 kV 120 kV 0.0 % Contrast concentration : 300 mgI/ml or 370 mgI/ml Scan with 100 kV 120 kV - 110 kV -10.2% 120 kV 100 kV -19.9 % Contrast Volume needed ? 0.5 gI/Kg * 70 kg 35 gI 117 ml = 93 ml = = 120 kV - 90 kV -30.4% (300 mgI/ml /1000) 0.3 120 kV - 80 kV -40.0% 0.5 gI/kg * 70 kg = 35 gI 94 ml = 77 ml = 120 kV 70 kV -49.2 % (370 mgI/ml / 1000) 0.37 Christian Canstein, MSc., Et. Al. : Reduction of contrast agent dose at low kV settings, www. siemens.com/healthineers 31 Restricted © Siemens Healthcare GmbH, 2018 Contrast enhancement : Needle, pressure and SIEMENS Healthineers contrast temperature 18 ૟૛ି ࡵࢍ࢓ Flow Rate = ࢉࢋ࢙/ ࢟ࢊ࢕࡮× ࢚ࢎࢍ࢏ࢋࢃ ࢒࢓ ࢔࢕࢏࢚ࢇ࢚࢘࢔ࢋࢉ࢔࢕࡯ 32 Restricted © Siemens Healthcare GmbH, 2018 Contrast enhancement :Needle, pressure and SIEMENS Healthineers contrast temperature Concentration Temperature 18°C 21°C 37°C 400 mgI/ml 189 140 101 370 mgI/ml 130 103 82 300 mgI/ml 75 60 54 Avoid !! Acceptable only for Best practice !! low FR & low concentration 33 Restricted © Siemens Healthcare GmbH, 2018 Contrast enhancement :Needle, pressure and SIEMENS Healthineers contrast temperature Gauge Color Code Diameter Pressure in room Outer (mm) Inner (mm) temperature with 400 mgI/ml (PSI) 18 G 1.27 0.84 190 20 G 0.91 0.61 248 22 G 0.71 0.41 298 34 Restricted © Siemens Healthcare GmbH, 2018 Contrast enhancement :Needle, pressure and SIEMENS Healthineers .. contrast temperature Needle Size Flowrate Max Note < 1 ml/s 26 G New Born/ Pediatric < 2 ml/s 24 G - Pediatric < 3 ml/s 22 G Rutine CT; Brain, Abdominal, Thorax, Leher. < 5ml/s 20 G - CTA Body dan CTA Coronary < 7 ml/s 18 G CT Perfusion dan CTA Coronary 35 Restricted © Siemens Healthcare GmbH, 2018 Injection Sequence for CT Brain – Neck Angiography (CARE SIEMENS Bolus) Healthineers Material Flowrate Volume NaCl 4.5 ml/ sec 15 ml Test Injection Contrast Media 4 ml/ sec 50 ml NaCl 4 ml/ sec 50 ml 36 Restricted © Siemens Healthcare GmbH, 2018 Injection Sequence for CT Brain – Neck Angiography (CARE SIEMENS Bolus) Healthineers Material Flowrate Volume NaCl 4.5 ml/ sec 15 ml Test Injection Contrast Media 4 ml/ sec 30 ml CM/ NaCl 4 ml/ sec 30 ml 60 % CM 40% NaCl NaCl 4 ml/ sec 50 ml 37 Restricted © Siemens Healthcare GmbH, 2018 Injection Sequence for CT Thorax – Pulmonary Artery (Test SIEMENS Bolus) Healthineers Material Flowrate Volume NaCl 5.5 ml/ sec 15 ml Test Injection Contrast Media 5 ml/ sec 15 ml NaCl 5 ml/ sec 50 ml 38 Restricted © Siemens Healthcare GmbH, 2018 Injection Sequence for CT Thorax – Pulmonary Artery (Test SIEMENS Bolus) Healthineers Contrast Media 5 ml/ sec 40 ml NaCl 5 ml/ sec 50 ml 39 Restricted © Siemens Healthcare GmbH, 2018 Injection Sequence for CT Thorax – Pulmonary Artery (CARE SIEMENS Bolus) Healthineers Material Flowrate Volume NaCl 5.5 ml/ sec 15 ml Test Injection Contrast Media 5 ml/ sec 40 ml NaCl 5 ml/ sec 50 ml 40 Restricted © Siemens Healthcare GmbH, 2018 Injection Sequence for CT Thorax – Pulmonary Artery SIEMENS Healthineers Material Flowrate Volume NaCl 5.5 ml/ sec 15 ml Test Injection Contrast Media 5 ml/ sec 40 ml CM/ NaCl 3 ml/ sec 50 ml 70 % CM 30% NaCl NaCl 5 ml/ sec 50 ml 41 Restricted © Siemens Healthcare GmbH, 2018 Injection Sequence for CT Thorax – Thoracic Aorta (CARE SIEMENS Bolus) Healthineers Material Flowrate Volume NaCl 5.5 ml/ sec 15 ml Test Injection Contrast Media 5 ml/ sec 60 ml NaCl 5 ml/ sec 50 ml 42 Restricted © Siemens Healthcare GmbH, 2018 Injection Sequence for CT Abdominal Artery (CARE Bolus) SIEMENS Healthineers Material Flowrate Volume NaCl 5.5 ml/ sec 15 ml Test Injection Contrast Media 5 ml/ sec 70 ml NaCl 5 ml/ sec 50 ml 43 Restricted © Siemens Healthcare GmbH, 2018 SIEMENS Contrast Media “Allergies” Healthineers .. Nausea and Severe Urticaria Respiratory Vomiting Wheezing Distress Headache Arrythmia Cardiac Arrest Itching Hypo/ Angiodermatitis Flushing Hypertension Seizures Author | Department 44 Restricted © Siemens Healthcare GmbH, 2018 Contrast Media for “Mother” SIEMENS Healthineers .. Table 4: Considerations and Recommendations on Use of lodinated or Gadolinium-based Contrast Agents in Pregnant and Lactating Patients Contrast Agent Pregnancy Lactation Comments Iodinated FDA category B no adverse Breast-feeding is safe Contrast agent should be effects in animal reproduc- after intravenous used if it may aid diag- tive studies, but there are iodinated contrast nosis and avoid necessity no controlled studies in agent administration; to repeat nondiagnostic pregnant women; informed systemic dose absorbed examination because con- consent is recommended by infant from breast trast agent was not admin- milk is <0.01% of dose istered; newborns should given to mother (6) be tested for hypothyroid- ism during first week of life (routine practice in North America) Gadolinium-based FDA category C-animal re- Breast-feeding is safe Gadolinium-based contrast production studies showed after gadolinium-based agent may be considered adverse effects on fetus, but contrast agent admin- if the radiologist and the there are no controlled stud- istration; systemic dose referring physician deem ies in humans; if benefits absorbed by infant that it is essential outweigh the risks, it may be from breast milk is used; no case reports of ad- <0.0004% of dose verse fetal effects; informed given to mother (6) consent is recommended Author | Department 45 Restricted © Siemens Healthcare GmbH, 2018 SIEMENS Contrast Media “Allergies” Healthineers .. Allergic Reactions to Contrast Agents During Pregnancy TABLE 2: Treatment of Selected Acute Reactions to IV Contrast Agents Including Suggested Modifications for Pregnant Patients Reaction Monitoring Medications Modification for Pregnant Patients Mild hives IV, vital signs, pulse oximetry, 02 by None or diphenhydramine 25-50 mg First-generation antihistamines face mask by mouth (chlorpheniramine, tripelennamine, diphenhydramine); alternatives are loratadine or cetirizine Diffuse erythema and hypotension IV, vital signs, pulse oximetry, 02 by Epinephrine IV 1-3 mL of 1:10,000 None face mask dilution; administer slowly into a running IV infusion of saline; can repeat up to 1 mg total OR intramuscular epinephrine 0.3 mg (1:1000), can repeat up to 1 mg total Mild bronchospasm IV, vital signs, pulse oximetry, 02 by Albuterol 2 puffs None face mask Moderate-to-severe bronchospasm IV, vital signs, pulse oximetry, 02 by Albuterol and epinephrine 0.3 mg None face mask intramuscularly (1:1000) Laryngeal edema IV, vital signs, pulse oximetry, 02 by Epinephrine IV 1-3 ml of 1:10,000 None face mask dilution; administer slowly into a running IV infusion of saline; can repeat up to 1 mg total OR epinephrine 0.3 mg intramuscularly (1:1000), can repeat up to 1 mg total Hypotension, bradycardia IV, vital signs, pulse oximetry, 02 by Atropine 0.6-1 mg IV Left lateral tilt. Atropine may cause a face mask, raise legs, IV fluids change in fetal behavior (e.g ., increase in fetal heart rate, decrease in fetal heart rate variability, decrease in fetal breathing) Author | Department 46 Restricted © Siemens Healthcare GmbH, 2018 Nephropathy Contrast SIEMENS Healthineers Impairment Of Renal Function—measured As Either A 25% Increase In Serum Creatinine (Scr) From Baseline Or A 0.5 Mg/Dl (44 µmol/L) Increase In Absolute Scr Value—within 48-72 Hours After Intravenous Contrast Administration (KDIGO ; Clinical Practice Guideline for Acute Kidney Injury) • Contrast Induced Nephrophaty was Reported Infrequent if Contrast Material Volume Adjusted for the Body Weight was Less than 5mL/ kg. • No Contrast Treshold Volume is Likely Safe for Contrast Induced Nephropathy Even Small Volume can Cause Contrast Induced Nephropathy for Critical Patients. • The Contrast Induced Nephrophaty Concensus Working Panel, Suggested Maximum Volume for Contrast Administration 100 ml for Patients with GFR less than 60mL/min per 1.73m2. 47 Kyongtae.T Bae ; Intravenous Contrast Medium Administration and Scan Timing at CT: Considerations and Approaches Restricted © Siemens Healthcare GmbH, 2018 SIEMENS Healthineers Nur Dwi Prasetyo Engineering success. MR & CT Application Specialist Pioneering healthcare. Together. HC APC ASN INA SV-CS EX Arkadia Office Park Tower F 18th Floor Jakarta Selatan P +62 (21) 27543100 F +62 (21) 27543101 M +62 8118 755 766 E nur.prasetyo@siemens-healthineers.com Restricted © Siemens Healthcare GmbH, 2017