Patient Safety News

May 2021

M&M Followup – Protocols for Anaphylaxis Prophylactic Cocktails

Below are the UNC Radiology contrast pre-treatment protocols for future procedures that are often referenced in allergy consult notes.

In cases of severe anaphylaxis, evaluation by allergy is important prior to the patient undergoing any imaging/procedures that require contrast.

If a different contrast agent can be used than the one implicated in severe anaphylaxis, that is preferred, along with pre-medications as below. In general, we recommend using a lower osmolarity/lower ionic agent if possible.

• 13 hour prep (PREFERRED)
  • Prednisone 50 mg po 13 hr, 7 hr, and 1 hr prior to contrast
  • Benadryl 50 mg po 1 hr prior to contrast
  • MUST have a driver

• 4 hour prep (EMERGENCY PREP ONLY)
  • Solumedrol 40 mg IV 4 hours prior to contrast
  • Benadryl 50 mg PO/IV 1 hour prior to contrast
  • Solumedrol 40 mg IV immediately prior to procedure

Article:
Controversies in Drug Allergy: Radiographic Contrast Media

UNC Contrast Reaction Card

References:
https://rads.web.unc.edu/body-division/contrast-reactions-and-extravasation/contrast-premedication/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5760058/

ICU Holds

• More information to follow – ICU team putting together cognitive aid
• At a minimum:
  • Resident/CRNA to have discussion about care plans with Attending
  • ICU Orders to be reviewed by all providers
  • ICU Orders to be followed
  • Request a contact person from surgical team prior to them leaving OR

Propofol and PONV

Study:
Determination of Plasma Concentrations of Propofol Associated with 50% Reduction in Postoperative Nausea

• To achieve PONV prophylaxis, it has been shown that a bolus of 10 mg followed by an infusion of 10 mcg/kg/min is sufficient.
• A full TIVA is NOT required to achieve PONV prophylaxis.

When searching for a document on the PSQI SharePoint site, you can search for a partial string (ie. “transport vent” rather than “transport ventilator”) by adding an asterisk at the end of the shortened word.

• Please be sure to check that your room is stocked with an adult Ambu Bag. It is important that an Ambu Bag is available for every case.

• Delays due to equipment issues or additional OR set-up should be reported as SAFE reports so they can be addressed by the appropriate periop staff.

Phase II Criteria (specific to ADULT patients)

• Implications
  • COVID+ Patients to Floor
  • Bypassing Phase I Recovery
• Temp 36-38, skin warm and dry
• Awake and cooperative or at preop baseline if intellectually/cognitively disabled (modified Aldrete)
• Hemodynamically stable (within 20% of preop baseline) – no longer requires medications to get to/stay at preop baseline (modified Aldrete)
• Pain < 5/10 or at preop baseline, especially if patient with chronic pain
• Absence of vomiting
• Protective airway reflexes intact with SpO₂ > 92% (modified Aldrete).

Please note: If you transfer a patient to any location other than PACU, please do not use the Handoff to Receiving Nurse button. Instead, use the Patient transported to ICU from OR button and change the text to reflect your recovery location.

Centurion NG Tube Securing Devices

• Our ICU’s have seen an incidence of pressure ulcers related to NG tube securement.

 

• Please watch the short <2 minute video below about the use of the Centurion NG tube securement device.
• Please utilize this device with any planned inpatient NG tube placement.

Recent Changes to Colorectal ERAS Pathway

In an effort to decrease surgical site infections in colorectal surgery, a change has been made to the colorectal ERAS pathway to help improve timely administration of prophylactic antibiotics.

Ideally these antibiotics are administered in the 15-60 minutes prior to surgical incision to achieve minimum inhibitory concentration. In order to mitigate potential delays in antibiotic administration, the specific prophylactic antibiotics are now listed in the colorectal ERAS pathway, in addition to a reminder to ensure the antibiotics are in the OR when the patient arrives.

We recommend starting the antibiotics as soon as they are verified at the pre-induction time-out, as there is often less than 15 minutes from intubation to incision in these cases. The new guidelines as they appear in the colorectal ERAS are shown below.

ChloraPrep 3ml Applicator Recall

On March 29, 2021 BD (Becton, Dickinson & Co.) initiated a voluntary recall of specific ChloraPrep 3ml applicators due to possible fungal contamination under certain environmental conditions. This recall does not include 3ml applicators found in kits.

Our excellent Anesthesia Technicians have done their best to remove all 3ml ChloraPreps from all the carts. However, since we are such a vast entity, there is bound to be some loose ones that slip through the cracks. These should not be used on patients and should be disposed of properly.

Until we receive a replacement, please use an alternative size 1.5ml or 10.5ml ChloraPrep for all procedures.

Local Anesthetics with Epinephrine

• Combination vials of local anesthetic with epinephrine remain on back order.
• We have run out of the following products:
  • Bupivacaine 0.25% w/ epinephrine 1:200,000; 30 mL vial
  • Bupivacaine 0.5% w/ epinephrine 1:200,000; 30 mL vial
  • Lidocaine 1% w/ epinephrine 1:100,000; 20 mL vial (limited supply)
• Adequate supply of all plain bupivacaine and lidocaine products.
• Should OR’s need to combine epinephrine with plain bupivacaine/lidocaine, please feel free to call OR Pharmacy for Calculations Tip Sheet or assistance.

Cisatracurium

• Reserve for patients with poor renal/liver function.
• Stock centralized in MAIN-OR Pyxis fridge for extended expiration dating.

Gelfilm

• Product remains unavailable.
• To obtain Durepair, please reach out to Materials Supply Chain.

Rifampin

• Shortage has resolved.

Protamine 50 mg/5 mL vials

• Stocking 250 mg/25 mL vials until shortage resolves.
• Larger vial size, but same concentration.

Physostigmine

• Manufacturing delays, with next release date expected in 2022.
• May need to centralize stock to Central Inpatient Pharmacy.

Drug Shortage information can also be found on the PSQI SharePoint site (available only when connected to the hospital’s secure network/wifi).