Carisoprodol intoxication: a comprehensive review

Authors: Zulkifli Amin, Steven Zulkifly, Stephen Diah Iskandar

Abstract

Carisoprodol has been widely used as a muscle relaxant agent. In Indonesia, carisoprodol is well-known as carnophene/zenith. Many retailers sell this drug illegally, especially to sex workers to make them feel more relaxed. Due to high incidence of carisoprodol abuse, Drug Enforcement Administration (DEA) categorized it into Schedule IV. Knowledge about pharmacokinetic and pharmacodynamic of carisoprodol are essential to be understood for proper diagnosis and management. Until now, there are only a few case reports about carisoprodol intoxication and no guideline has been published. This article aims to provide an overview about carisoprodol intoxication, starting from the mechanism of action to its management. In the body, carisoprodol is metabolized to meprobamate by CYP2C19 liver enzyme. Diagnosis of carisoprodol intoxication is challenging because carisoprodol and meprobamate have opposite effect. Gastric lavage, administration of flumazenil and bemegride may be effective for acute intoxication case.

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The use of furosemide in critically ill patients

Authors: Mayang Indah Lestari, Yohannes WH George

Abstract

Critically ill patients are those with life threatening illness who, without adequate medical interventions, will suffer from severe morbidity and occasionally mortality. One of the most frequent cause of morbidity and mortality in critically ill patients is distributive or vasogenic shock. After liberal fluid resuscitation, an increase in microvascular hydrostatic pressure, fluid accumulation of interstitial compartment, and impaired organ function occur. Normally this phase, called ebb phase, will return to flow phase where inflammatory mediators homeostasis occurs, plasma oncotic pressure restored, diuresis, extravascular fluid mobilized and negative fluid balance occur. In certain group of patients, there is persistent systemic inflammation, plasma leakage, and failure to achieve flow phase spontaneously, which lead to fluid overload and global increased permeability syndrome (GIPS). GIPS causes venous resistance of organs within compartment, resulting in decreased perfusion pressure and organ failure. In this condition, it is necessary to remove the fluid actively and one of the drugs that can be used is furosemide. This literature review will describe what happens in critically ill patients, how furosemide works, what its benefits are in critically ill patients, what side effects and potential toxicities of furosemide.

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Accuracy of calculated creatinine among amputees: case presentation and literature review

Authors: Janay Bailey, Elizabeth Awudi, Charlene Kalani, George Udeani, Joseph Varon, Salim Surani

Abstract

Dosing vancomycin for patients who do not follow population pharmacokinetics can be challenging. Standard predictive clinical equations do not account for extreme patient characteristics. In particular, serum creatinine is significantly reduced while creatinine clearance is overestimated in patients with amputations. The “missing” body part must be accounted for when executing a dosing regimen for these challenging patients. In addition, health care professionals must judiciously review the patient holistically, practice evidence-based medicine, and consider the overestimation of renal function, when calculating doses for this and other agents. While current literature does not provide a clear consensus for this population, there are several factors to take into consideration when determining the optimal dose in patients presenting to the hospital requiring medications dosed by changes in renal function. We recently had one such case.

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Sodium bicarbonate buffering for metabolic acidosis does not hasten hemodynamic improvement in septic shock: a retrospective analysis of a 5-year period

Authors: John H. Ferguson, Maurice M. Otterstetter, Nicholas JK Tranchida, James DeFoe

Abstract

Objective: Severe metabolic acidosis often occurs in the setting of septic shock and hemodynamic collapse. Acid buffering agents such as sodium bicarbonate are often used to improve acidosis, although the hemodynamic benefit of improving the serum pH is uncertain and has been evaluated only in a few small clinical studies.

Design: A retrospective cohort of patients with vasopressor-dependent septic shock who were treated with sodium bicarbonate.

Setting: A single-center mixed medical-cardiac-surgical intensive care unit.

Patients and participants: 21 patients with vasopressor-dependent septic shock who were treated with sodium bicarbonate. Patients with vasopressor-dependent septic shock who were not treated with sodium bicarbonate served as a matched control group.

Interventions: The primary endpoint was the change in norepinephrine equivalent (NEEq) dose at 24 and 48 hours after initiation of sodium bicarbonate when compared to non-sodium bicarbonate treated patients. Secondary outcomes included: hospital mortality, the impact of hypocalcemia on vasopressor requirements, and the impact of hypercapnia on vasopressor requirements in sodium bicarbonate treated patients.

Measurements and results: Patients with vasopressor-dependent septic shock who were not treated with sodium bicarbonate had no difference in the decline of vasopressor requirements than those administered sodium bicarbonate at 24 hours (0.09 μg/kg/min; 95% CI, [-0.23, 0.05], p=0.19) and at 48 hours (0.04 μg/kg/min; 95% CI [-0.11, 0.18], p=0.60). In patients with pH≤7.15, there was no difference in the change in NEEq dose between sodium bicarbonate treated or non-bicarbonate treated patients at 24 hours (0.05 μg/kg/min, 95% CI, [-0.09, 0.11], p=0.69) or at 48 hours (0.19 μg/kg/min, 95% CI, [-0.52, 0.14], p=0.17).

Conclusions: Administration of sodium bicarbonate did not improve vasopressor requirements at 24 or 48 hours, even in patients with a pH less than 7.15. Mortality and vasopressor needs are high in patients with pH less than 7.15 and unaffected by sodium bicarbonate administration.

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Predictors of perceptions of patient safety culture and frequency of event reporting by critical care nurses in Oman: a model-building approach

Authors: Qasim Al Ma'mari, Loai Abu Sharour, Omar Al Omari

Abstract

Objectives: This study was conducted to identify the predictors of critical care nurses’ perceptions of patient safety culture and the frequency of event reporting.

Methods: A cross-sectional study design was used. Patient safety culture was assessed using the Hospital Survey on Patient Safety Culture, which was completed by 270 critical care nurses working in two hospitals in Oman.

Results: The results revealed that teamwork within units had the highest positive score (91.8%), followed by organisational learning and continuous improvement (86.3%) and feedback and communication about errors (77.7%). Regression analysis showed that teamwork within units, supervisor/manager expectations and actions promoting patient safety, organisational learning and continuous improvement, management support for patient safety, feedback and communication about errors, teamwork across units, staffing, hospital handoffs and transitions, and patient safety grade were all predictors of the overall perception of patient safety culture among critical care nurses in Oman (R2=0.462, adjusted R2=0.186; F=7.83, p<0.0001). Regression analysis showed that openness in communication, income, non-punitive response to errors, organisational learning and continuous improvement, and feedback and communication about errors were predictors of the frequency of events reporting among critical care nurses in Oman (R2=0.24, adjusted R2=0.043; F=3.41, p<0.0001).

Conclusion: Patient safety culture is an important indicator of the quality of care, and represents one of the key performance indicators in the healthcare setting.

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Eosinopenia as an indicator for organ dysfunction in septic patients

Authors: Syafri Kamsul Arif

Abstract

Sepsis is one of the most common causes of morbidity and mortality in intensive care unit (ICU).

Objective: To determine the possibility of eosinophil as indicator for organ dysfunctions in sepsis patients and septic shock patients in ICU.

Design: Prospective.

Setting: Intensive care unit (ICU) Wahidin Sudirohusodo Hospital, Makassar.

Participants: Adult sepsis patients admitted to ICU from October to December 2018.

Measurement: Eosinophils count and Sequential Organ Failure Assessment (SOFA) scores were assessed within 24 hours and after 72 hours after patients admitted in ICU. The patients were categorized into non- and organ dysfunction groups based on SOFA scores after 72 hours. Outcomes of the patients then evaluated at day 7.

Results: Thirty four sepsis patients participated in the study. The mean of SOFA scores between non- and organ dysfunction groups were not different within 24 hours after admission but then showed a difference after 72 hours (p=0.558 and p<0.001, respectively). In contrast with non-organ dysfunction patients, after 72 hours the eosinophil count in organ dysfunction group decreased (from 0.51 to 0.15 cells/µl). There was a negative correlation between eosinophil count and SOFA scores at 72 hours (p=0.043; rho: -0.350). In discriminating non-organ dysfunction and organ dysfunction groups, the area under the receiver operating characteristic curve was 0.714. Eosinophils at 0.5 cells/µl (eosinopenia) yielded a sensitivity of 92.8%, a specificity of 66.6%, a positive predictive value of 92.8%, and a negative predictive value of 66,6%.

Conclusion: Eosinopenia levels might be used as an indicator for organ dysfunction in critically ill patients, including sepsis patients, in area where laboratory facility is limited.

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Anesthesia and intensive care management in acute ischemic stroke patient

Authors: Hamzah, Prananda Surya Airlangga, Abdulloh Machin, Nancy Margarita Rehatta

Abstract

Acute ischemic stroke is a brain functional disorder, which cause high disability and mortality rate worldwide, the second most common cause of dementia, and the third leading cause of death. It has enormous clinical, social, and economic implications and demands a significant effort from both basic scientists and clinicians in the quest for understanding the underlying pathomechanisms and producing suitable preventive measures and successful therapies. Management of acute ischemic stroke has been revolutionized by the introduction of several interventions, such as prehospital and stroke unit care, intravenous tissue plasminogen activator therapy within 4.5 hours of stroke onset, aspirin therapy within 48 hours of stroke onset, decompressive craniectomy for supratentorial malignant hemispheric cerebral infarct, and more recently endovascular therapy for anterior circulating stroke. Also, special attention in management of vital systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose. In line with this, the role of neuroanesthesiologists and neuro critical care in managing acute ischemic stroke become more prominent.

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Do Asian physicians manage hypertensive crisis properly? A Southeast Asia survey analysis

Authors: Abbas Alshami, Johanan Luna, America Avila, Salim Surani, Joseph Varon

Abstract

Purpose: Hypertension remains a common cause of morbidity and mortality worldwide, and proper management can prevent death. Over the last few decades, several changes in definitions, clinical manifestations, and management have occurred. We aimed to investigate the extent of knowledge about these changes, as the pertain to acute elevations of blood pressure among physicians in Southeast Asia.

Methods: A cross-sectional survey was created and validated. The survey included 25 questions about the definitions of hypertensive urgencies and emergencies, clinical presentations, ideal rate of blood pressure reduction, and other questions. Surveys were distributed at the Asia Pacific Symposium held in Indonesia in August 2017. Descriptive analysis was conducted using IBM SPSS Statistics™ version 25.0 (IBM Corporation, Armonk, NY).

Results: A total of 145 surveys were completed by physicians from India, Indonesia, South Korea, Philippines, Singapore, and Sri Lanka. Of them, only 49.6% (n=72) knew the normal blood pressure cut-off limits, and 19.3% (n=28) did not recognize the differences between hypertensive urgencies and emergencies. Moreover, 53.7% (n=78) of respondents was not aware that hypertensive urgency can be completely asymptomatic. Sixty-four point eight percent (n=94) indicated that acute cerebrovascular accidents were the most common end-organ damage from hypertensive emergencies. In addition, only 44.1% (n=64) were aware of the ideal rate of blood pressure reduction, and 50.3% (n=73) considered sublingual nifedipine as an appropriate choice in hypertensive crisis management.

Conclusions: A significant percentage of physicians in Southeast Asia lack knowledge about hypertensive crisis definitions, clinical presentations, and management.

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Corticosteroids and gastrointestinal bleeding in critical care: a systematic review and meta-analysis

Authors: Paul E. Marik, Mit P. Patel, Joseph Varon

Abstract

Background: Current belief suggests that patients receiving corticosteroids have an increased risk of bleeding from stress ulceration and that these patients should receive stress ulcer prophylaxis. This issue is important as many ICU patients receive corticosteroids and the pharmacologic agents used for stress ulcer prophylaxis are associated with adverse events.

Aim: The goal of this systematic review and meta-analysis was to compare the rate of clinically significant (overt) gastrointestinal (GI) bleeding in critically ill patients receiving corticosteroids versus placebo.

Methods: We searched PubMed, Embase, and the Cochrane database from inception through December 2018. In addition, the bibliographies of selected articles were reviewed for relevant studies and included if inclusion criteria were met. Included studies were randomized, placebo-controlled and blinded studies that compared treatment with corticosteroids for any indication in a patient population that included only ICU patients. Primary outcome of interest was rate of clinically significant GI bleeding in patients treated with corticosteroids versus placebo. Results were expressed as risk ratio (RR) with accompanying 95% confidence interval (CI). Heterogeneity, sensitivity analysis, and risk of bias were explored. In addition, we did a subgroup analysis according to the use of “low-dose” (<400 mg hydrocortisone or equivalent/day) versus “high-dose” corticosteroid.

Results: Thirty-five studies, which enrolled 16,659 patients, met inclusion criteria and were analyzed. Significant GI bleeding was recorded for 355 patients (overall rate of 2.1%). Summary data demonstrated no difference in the risk of GI bleeding between those treated with corticosteroids versus placebo (RR 1.08; 95% CI 0.88-1.33; p=0.46) with minimal heterogeneity between studies (Q statistic p=0.86, I2=0%). Similarly, there was no significant difference in the risk of GI bleeding in either the low (RR 1.04; 95% CI 0.78-1.38) or the high dose groups (RR 1.13; 95% CI 0.84-1.53) and in those studies at low risk of bias (RR 1.16; 95% CI 0.91-1.49) and those at a high risk of bias (RR 0.88; 95% CI 0.6-1.28).

Conclusion: This meta-analysis did not identify a clinically significant difference in the rate of overt GI bleeding in critically ill patients receiving corticosteroids as compared to placebo. The role of stress ulcer prophylaxis in these patients remains uncertain.

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The effect of N-acetylcysteine on the myeloperxidase and Tei index in patients with acute myocardial infarction

Authors: Trisulo Wasyanto, Ahmad Yasa, Nuka Meriedlona

Abstract

Bacground: Myeloperoxidase (MPO) is a strong oxidant and toxic to microorganisms with excess production causing tissue damage. We aimed to determine the effect of N-acetylcysteine (NAC) 600 mg orally 3 times a day for 3 consecutive days on MPO levels and left ventricle myocardial performance index (LVMPI/Tei index) in ST elevation myocardial infarction (STEMI) patients treated with fibrinolytics.

Methods: Pre- and post-design, single blind experimental randomized trial, conducted on 32 patients with STEMI at Intensive Cardiovascular Care Unit (ICVCU). The subjects were divided into 2 groups: 17 patients received 600 mg t.i.d NAC for 72 hours and 15 controls. MPO levels before and after 72 hours and Tei index 72 hours after NAC therapy were measured. Statistical analysis of MPO level and Tei index were analyzed with SPSS 22. Tei index was measured using the pulsed wave Doppler (PWD) and tissue Doppler imaging (TDI).Results: NAC administration showed decrease in the marker of MPO (112.76±57.28 vs 180.40±69.03, p=0.001) and delta MPO (-50.15±46.62 vs 12.06±108.65) 72 hours after NAC therapy compared with control. NAC improved the LVMPI value compared to the control group. Tei index examination using PWD (0.39±0.11 vs 0.49±0.08, p=0.005) and that using TDI (0.41±0.08 vs 0.57±0.08, p=0.001) showed improved values for NAC administration than those with controls.Conclusion: NAC 600 mg orally 3 times a day for 3 consecutive days can reduce MPO levels and improve diastolic function by decreasing LVMPI values.

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