Bolus Timing

TeleStroke consultation can therefore be performed quickly. Its efficiency compares quite favorably to the management of patients in rural Ontario" who receive rt-PA after transfer from a rural hospital to a tertiary-care center (the so-called ship and drip model). The patients located in mral Ontario had a mean total time of 138 minutes between presentation at the rural facility and dmg delivery at the tertiary-care center. The door-to-bolus time at the community hospitals linked to our TeleStroke service was 106 minutes, only 36 minutes longer than that measured by the urban acute stroke service in Houston, which permitted a mean door-to-bolus time of 70 minutes. Whereas the door-to-consult time within a telemedicine system may decrease with training and practice, interfacility transfer times, such as those observed in Ontario, are not easily shortened. 

Fig. 5.6a-d. CE-MRA failed bolus timing resulted not only in a weak artery signal, but also artificial enhancement of vessel walls (ringing artifacts), similar to intraluminal thrombus. Examination was repeated and revealed normal vessel enhancement... 

Time to peak plasma concentration depends on the rate of IV dosing but is usually achieved in 45—90 seconds. Therapeutic plasma concentrations are 1.5—5.0 )J.g/mL, and concentrations above 5 )J.g/mL maybe toxic. The elimination half-life after a bolus iv dose is 8 min the elimination half-life after a 24 h iv infusion is about 100 min. The dmg is eliminated by the kidneys. Ten percent is unchanged and the remainder is in the form of inactive metabolites... 

Compared to streptokinase, urokinase has been less extensively studied because of its high cost, ie, about 10 times that of a comparable treatment with streptokinase. In addition to the indications described for streptokinase, urokinase is indicated for use in patients with prior streptokinase treatment, or prior Streptococcal infection. Urokinase is commonly used at a loading dose of 4400 units /kg, with a maintenance intravenous infusion dose of 4400 units/kg/h for thromboses other than acute myocardial infarction. In the latter case, a much larger dose, ie, 0.5—2.0 million units/h or a bolus dose of 1.0 million units followed by a 60-min infusion with 1.0 million units, has been found optimal (106). An intracoronary dose of 2000 units/min for two hours was used in one comparative study with intracoronary streptokinase (107). In this study, urokinase exhibited efficacy equivalent to streptokinase with fewer side effects. Other studies with intracoronary urokinase have adrninistered doses ranging from 2,000 to 24,000 units/min with a reperfusion efficacy of 60—89% (108—112). In another urokinase trial, 2.0 million units were adrninistered intravenously, resulting in a thrombolytic efficacy of 60% (113). Effectiveness in terms of reduction in mortaUty rate has not been deterrnined because of the small number of patients studied. 

The release of steroids such as progesterone from films of PCL and its copolymers with lactic acid has been shown to be rapid (Fig. 10) and to exhibit the expected (time)l/2 kinetics when corrected for the contribution of an aqueous boundary layer (68). The kinetics were consistent with phase separation of the steroid in the polymer and a Fickian diffusion process. The release rates, reflecting the permeability coefficient, depended on the method of film preparation and were greater with compression molded films than solution cast films. In vivo release rates from films implanted in rabbits was very rapid, being essentially identical to the rate of excretion of a bolus injection of progesterone, i. e., the rate of excretion rather than the rate of release from the polymer was rate determining. 

CTP is a relatively recent development in acute stroke imaging that is already in routine clinical use in many centers. CTP and MRP are similar in that both techniques are based on rapid serial image acquisition during intravenous injection of a bolus of contrast material. In both techniques, measurements of density over time (for CTP) or signal intensity over time (for MRP) are converted to contrast agent-versus-time curves, and these are processed in similar ways to yield the same perfusion measurements (most often CBV, CBF, and MTT). Example CTP images are shown in Figure 2.12. 

The Interventional Management of Stroke (IMS I) Study was a multicenter, open-labeled, single-arm pilot study in which 80 patients (median NIHSS 18) were enrolled to receive IV rt-PA (0.6 mg/kg, 60 mg maximum, 15% of the dose as a bolus with the remainder administered over 30 minutes) within 3 hours of stroke onset (median time to initiation 140 minutes). " Additional rt-PA was subsequently administered via a microcatheter at the site of the thrombus in 62 of the 80 patients, up to a total dose of 22 mg over 2 hours of infusion or until complete recanalization. Primary comparisons were with similar subsets of the placebo and rt-PA-treated subjects from the NINDS rt-PA Stroke Trial. The 3-month mortality in IMS I subjects (16%) was numerically lower but not statistically different than the mortality of the placebo (24%) or rt-PA-treated subjects (21%) in the NINDS rt-PA Stroke Trial. The rate of symptomatic ICH (6.3%) in IMS I subjects was similar to that of the rt-PA-treated subjects (6.6%) but higher than the rate in the... 

This should be compared with the initial plasma concentration of 50 pg F which is obtained when the same dose D is injected as a single bolus. The final concentration Cp(x) is also still far from the steady-state concentration (72.2 pg 1" ), since the duration of infusion x is only equal to once the half-life time of the dmg t,/2 (60 min). 

FIGURE 1. Change in the apparent volume of distribution of PCP as a function of time following administration of an intravenous bolus dose of 3H-PCP (6.4 pg) in a male dog (19.5 kg)... 

Several adaptive mechanisms by the kidney limit effectiveness of loop diuretic therapy. Postdiuretic sodium retention occurs as the concentration of diuretic in the loop of Henle decreases. This effect can be minimized by decreasing the dosage interval (i.e., dosing more frequently) or by administering a continuous infusion. Continuous infusion loop diuretics may be easier to titrate than bolus dosing, requires less nursing administration time, and may lead to fewer adverse reactions. 

Epidural analgesia is frequently used for lower extremity procedures and pain (e.g., knee surgery, labor pain, and some abdominal procedures). Intermittent bolus or continuous infusion of preservative-free opioids (morphine, hydromorphone, or fentanyl) and local anesthetics (bupivacaine) may be used for epidural analgesia. Opiates given by this route may cause pruritus that is relieved by naloxone. Adverse effects including respiratory depression, hypotension, and urinary retention may occur. When epidural routes are used in narcotic-dependent patients, systemic analgesics must also be used to prevent withdrawal since the opioid is not absorbed and remains in the epidural space. Doses of opioids used in epidural analgesia are 10 times less than intravenous doses, and intrathecal doses are 10 times less than epidural doses (i.e., 10 mg of IV morphine is equivalent to 1 mg epidural morphine and 0.1 mg of intrathecally administered morphine).45... 

The most commonly used corticosteroids are methylpred-nisolone (IV and oral) and prednisone (oral), although prednisolone and dexamethasone also have been shown to be effective for organ transplantation. Corticosteroid doses vary by center-specific protocols, organ type, and patient characteristics. A typical taper would include an IV 100 to 500 mg bolus of methylprednisolone at the time of transplant and then a taper over 5 to 7 days to a maintenance dose of prednisone 20 mg/day or complete cessation.2,7 It is important for practitioners to know that approximately 4 mg methylprednisolone is equivalent to 5 mg prednisone and 0.75 mg dexamethasone.11 At most transplant centers, therapeutic drug monitoring of corticosteroids is not employed. Corticosteroids are associated with a variety of acute and chronic toxicides. The most common adverse events have been summarized in Table 52-5. 

Two sets of curves are shown, one for anhydrous and one for hydrated boluses. As with the GITS system, there is a lag time associated with the onset... 

Another approach to the pulsatile delivery of drugs with an osmotic pressure driven system has been suggested by Amidon et al. [66], This system provides the option of an immediate bolus dose and a second dose that can be timed to be released at some subsequent point following the administration of the dosage form. One or both of the doses can be composed of multiparticulates, for example, that would themselves be sustained release systems. 

A second form of motility in the large intestine is mass movement. Three or four times per day, typically after a meal, a strong propulsive contraction occurs that moves a substantial bolus of chyme forward toward the distal portion of the colon. Mass movements may result in the sudden distension of the rectum that elicits the defecation reflex. 

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