Administration Of Bolus Doses Research Articles

Comparison of bolus dose administration of propofol and dexmedetomidine for incidence of emergence delirium in pediatric patients undergoing surgery with general anesthesia: A randomized, double-blind trial

Abstract Background and Aims: Emergence delirium (ED) during the postanesthesia recovery phase presents significant challenges, especially among pediatric patients, with incidence rates spanning from 2% to 80%. This study sought to assess and compare the effectiveness of propofol and dexmedetomidine in addressing ED in pediatric patients undergoing sevoflurane anesthesia. The primary aim was to ascertain the prevalence of ED in both treatment cohorts, while secondary outcomes encompassed postoperative pain, hemodynamic responses, and the occurrence of complications. Material and Methods: Eighty children aged 2–6 years scheduled for short infraumbilical surgeries under general anesthesia were recruited in this trial. Propofol (1 mg/kg) or dexmedetomidine (0.3 μg/kg) was administered 10 min before completion of surgery. The Paediatric Anaesthesia Emergence Delirium scale was employed to evaluate ED every 5 min following extubation, wherein a score exceeding 12 was indicative of ED. Postoperative sedation was assessed using the Ramsay Sedation Scale, while pain levels were determined through the Face, Legs, Activity, Cry, and Consolability (FLACC) score. Any potential complications were closely monitored. Results: The incidence of ED at extubation was 2.50% and 70% in group D and P, respectively, and the trend of lower ED incidence was consistently observed at 5, 10, 15, and 30 min postextubation. The relative risk ratio at extubation was 4.103 (95% confidence interval: 2.49–6.76), highlighting a significant reduction of 4.1 times in the risk of ED when dexmedetomidine was administered. The dexmedetomidine group exhibited a lower incidence of postoperative pain. Conclusion: In comparison to propofol, dexmedetomidine demonstrated superior efficacy in reducing ED and postoperative pain in pediatric patients during general anesthesia, when administered before completion of surgery.

Bolus Dose Administration of Fentanyl in Obese Children: Do Settle for Less

Bolus Dose Administration of Fentanyl in Obese Children: Do Settle for Less

984-P: Importance and Use of Smart Insulin Pens with Connectivity for Diabetes Management

Smart insulin pens have the potential to fulfill some of the unmet needs of people with diabetes through the accurate administration of bolus doses, the simplification of documentation relating to diabetes therapy, the improvement of communication and the quality of advice given to patients. 305 (2021) and 336 diabetologists in Germany (2022; 38% female, average age 55.2 years) were asked via an online survey about the importance and use of smart insulin pens. In 2022, only 4.8% of all people with type 1 diabetes and 1.5% of all people with type 2 diabetes used a smart pen. The total estimated utilization in 5 years is 18.3% (2021: 23.9%). The importance of smart pens is currently estimated by diabetologists at 8.0%, which is not very high and lower than in 2021 (15.5%). This also applies to the estimated relevance in 5 years (2022: 24.7 %; 2021: 37.9 %). However, 29.7% of all people with type 1 diabetes are considered to have an indication for a smart pen, 30.8% of people with type 2 diabetes and basal insulin therapy, and 37.6% with multiple injection therapy. The main barriers to smart pens identified were patient preference for prefabricated pens (54.6% agreement), low added benefit (49.4%), lack of interoperability with glucose analysis software (44.3%), lack of interoperability with apps (35.6%), too little choice (need to change insulin), and too high cost (33.9%). Despite a very positive attitude towards digitization of diabetes therapy among physicians (2021: 81.9%; 2022: 86.3%), smart pens are currently used only very rarely and their importance for diabetes therapy is considered rather low. Better, simpler, and patient-friendly solutions are needed so that all types of smart insulin devices can be read easily by glucose management software and users experience perceivable benefits. Disclosure L.Heinemann: Consultant; 9am.health. D.Ehrmann: Advisory Panel; Roche Diabetes Care, mySugr, Dexcom, Inc., Speaker's Bureau; Berlin-Chemie AG, Dexcom, Inc. N.Hermanns: Advisory Panel; Insulet Corporation, Research Support; Sanofi-Aventis Deutschland GmbH, Roche Diagnostics, Becton, Dickinson and Company, Speaker's Bureau; Dexcom, Inc., Berlin-Chemie AG. T.Roos: None. B.Kulzer: Advisory Panel; Berlin-Chemie AG, Abbott Diabetes, Bayer Inc., Dexcom, Inc., Novo Nordisk, Insulet Corporation, embecta, Research Support; Sanofi, Roche Diabetes Care.

Comparative study of intravenous diuretics therapy-bolus versus infusion regimen in acute decompensated heart failure

Background: Heart failure (HF) is a growing problem worldwide; more than 20 million people around the world are affected. The objective of the study was to compare the effect of different modes of administration of intravenous diuretic –bolus versus infusion, in acute decompensated heart failure in relation to diuresis and electrolyte balance.Methods: This prospective study was conducted in Darbhanga Medical College and hospital, Laheria sarai between October 2014 to November 2016. Patients of acute decompensated heart failure attending medical emergency ward and Intensive care unit of medicine department of Darbhanga Medical College and hospital, Laheria sarai were selected and grouped randomly as per inclusion and exclusion criteria.Results: The main findings of our study were greater diuresis in the first 24 h of admission with bolus dose. No difference in serum sodium or serum potassium levels between the groups.Conclusions: All three modes of diuretic therapies can be practiced with no difference in worsening of electrolyte levels. Bolus dose administration with its rapid volume loss might be a more effective diuretic strategy in our country with limited health resources.

Evaluation of an ex-vivo neonatal extracorporeal membrane oxygenation circuit on antiepileptic drug sequestration.

Antiepileptic dosing information used to manage neonatal patients receiving extracorporeal membrane oxygenation (ECMO) is limited. The objective of this study is to quantify the extent of sequestration of various antiepileptic drugs using an ex-vivo neonatal ECMO circuit. Two neonatal closed-loop ECMO circuits were prepared using a Rotaflow centrifugal pump, custom polyvinylchloride tubing and a Quadrox-i Neonatal membrane oxygenator. After 5 minutes of circuit priming and stabilization with normal saline/albumin or expired human whole blood, single boluses of levetiracetam (200 mg), lacosamide (20 mg), and phenytoin (200 mg) were injected into the circuit. To account for spontaneous drug degradation, two polyvinylchloride beakers were filled with normal saline/albumin or expired human whole blood and equivalent antiepileptic drug doses were prepared. Simultaneous pharmacokinetic samples were collected from the control solution and the pre-centrifugal pump, pre-oxygenator, and post-oxygenator sampling ports from each circuit. Similar drug recovery profiles were observed among the three sampling sites investigated. Percent drug sequestration after a 24-hour circuit flow period was relatively similar between the two different circuits and ranged between 5.5%-13.2% for levetiracetam, 18.4%-22.3% for lacosamide, and 24.5%-30.2% for phenytoin. A comparison at 12 and 24 hours demonstrated similar percent drug sequestration across all three drugs in each circuit. Percent drug sequestrations for levetiracetam and lacosamide were less than 20% and for phenytoin were as high as 30% based on the sampling following single bolus dose administration into a neonatal ECMO circuit. Careful consideration of patient clinical status should be taken in consideration when optimizing antiepileptic therapy in neonates receiving ECMO.

Iatrogenic withdrawal syndrome frequently occurs in paediatric intensive care without algorithm for tapering of analgosedation.

Analgesics and sedatives are key elements to reduce physiological and psychological stress associated with treatment in paediatric intensive care. Prolonged drug use may induce tolerance and development of iatrogenic withdrawal syndrome (IWS) during the tapering phase. Our primary aim was to describe the prevalence of IWS among critically ill ventilated patients in two Norwegian paediatric intensive care units (PICUs), and secondary to investigate what motivated bedside nurses to administer additional drug doses. Mechanically ventilated patients (n=40) from newborn to eighteen years of age, with continuous infusions of opioids and benzodiazepines for 5days or more, were included consecutively from May 2016 to June 2018. By using Withdrawal Assessment Tool-1 (WAT-1) twice daily we recorded the prevalence of IWS. Additionally, we recorded signs and symptoms that led bedside nurses to administration extra bolus medication. Peak WAT-1 score indicated an IWS prevalence of 95% in this selected group. The first days of the tapering phase were most critical for IWS. The most frequent symptoms triggering administration of additional bolus doses were agitation/restlessness, and thiopental and propofol were the bolus drugs used most frequently. IWS affected 95% of the children having received infusions of opioids and benzodiazepines for 5days or more in PICUs without a tapering protocol for these drugs. This calls for implementation and testing of such weaning protocols.

Management of a parenteral opioid shortage using ASHP guidelines.

PurposeManagement of an acute shortage of parenteral opioid products at a large hospital through prescribing interventions and other guideline-recommended actions is described.SummaryIn early 2018, many hospitals were faced with a shortage of parenteral opioids that was predicted to last an entire year. The American Society of Health-System Pharmacists (ASHP) has published guidelines on managing drug product shortages. This article describes the application of these guidelines to manage the parenteral opioid shortage and the impact on opioid dispensing that occurred in 2018. Our approach paralleled that recommended in the ASHP guidelines. Daily dispensing reports generated from automated dispensing cabinets and from the electronic health record were used to capture dispenses of opioid medications. Opioid prescribing and utilization data were converted to morphine milligram equivalents (MME) to allow clinical leaders and hospital administrators to quickly evaluate opioid inventories and consumption. Action steps included utilization of substitute opioid therapies and conversion of opioid patient-controlled analgesia (PCA) and opioid infusions to intravenous bolus dose administration. Parenteral opioid supplies were successfully rationed so that surgical and elective procedures were not canceled or delayed. During the shortage, opioid dispensing decreased in the inpatient care areas from approximately 2.0 million MME to 1.4 million MME and in the operating rooms from 0.56 MME to 0.29 million MME. The combination of electronic health record alerts, increased utilization of intravenous acetaminophen and liposomal bupivacaine, and pharmacist interventions resulted in a 67% decline in PCA use and a 65% decline in opioid infusions.ConclusionA multidisciplinary response is necessary for effective management of drug shortages through implementation of strategies and practices for notifying clinicians of shortages and identifying optimal alternative therapies.

Quantification of neurotransmitters in microdialysate samples following quetiapine dosing to schizophrenia phenotyped rats using a validated LC-MS/MS method

A versatile method was developed and validated for simultaneous determination of the monoamine neurotransmitters (MNT) dopamine (DA), 3–4-dyhydroxyphenilacetic acid (DOPAC), homovanilic acid (HVA), serotonin (5-HT) and 5-hydroxyindolacetic acid (5-HIAA) in rat brain microdialysate samples using high-performance liquid chromatography tandem mass spectrometry (LC-MS/MS). The method allowed for small sample volume, using positive and negative ionization mode in a single run analysis without any derivatization or cleanup steps. Analytes were quantified at concentrations ranging from 100 ng/mL to 0.05, 10, 0.5, 0.1 or 1 ng/mL (lower limit of quantification, LLOQ) of DA, DOPAC, HVA, 5-HT and 5-HIAA, respectively, showing linearity (r > 0.98), accuracy, and precision (R.S.D ± 15%) according to validation limits accepted by international guidelines. The method was successfully applied for monitoring the concentration changes of MNT in microdialysate samples from medium prefrontal cortex of Wistar rats in a neurodevelopmental model of schizophrenia before and after quetiapine 5 mg/kg i.v. bolus dose administration. No alterations in MNTs were observed in schizophrenia phenotyped rats (SPR) in comparison to the baseline shading a light on the limited response rate to antipsychotic drugs observed in chronic schizophrenic patients.

A novel protocol for accurate and reliable postoperative bolus administration of recombinant factor VIIa using an automated mini-pump system.

Recombinant FVIIa (rFVIIa) is widely used to manage bleeding risk during and after surgery in patients with haemophilia complicated by inhibitors. In the postoperative period, rFVIIa must be delivered frequently and regularly to maintain haemostasis, considering its short half-life. Preparation and manual administration of bolus doses of rFVIIa at regular intervals may place a strain on available nursing resources. A programmable mini-pump may offer an approach to facilitate regular administration of bolus doses of rFVIIa at specified intervals. To investigate if a mini-pump is a practical and effective way to deliver rFVIIa in the postoperative period. It was first necessary to establish that rFVIIa remains stable and sterile in the mini-pump reservoir for an extended period. Four days after loading the mini-pump under sterile conditions no evidence of bacterial or fungal growth was observed and in vitro procoagulant activity of rFVIIa remained stable. The mini-pump was used to deliver rFVIIa as bolus doses to two patients with inhibitors who had undergone surgery. Nurses were asked to report their satisfaction with the use of the mini-pump using a specific questionnaire. Haemostasis was evaluated as excellent in both cases; nurses were satisfied with use of the mini-pump. This pilot study shows that intermittent delivery of rFVIIa at fixed intervals using an automated mini-pump offers accurate and reliable administration in the postoperative setting. This approach may reduce burden on nursing staff, potentially minimize the risk of human error and avoid delay in administration of rFVIIa.

Vitamin D and Cardiovascular Disease: An Update

In the clinical setting, administration of high daily or bolus doses of vitamin D is often solely based on 25-hydroxyvitamin D [25(OH)D] testing. This review summarizes the evidence of the effect of vitamin D on cardiovascular disease (CVD). Meta-analyses of randomized controlled trials (RCTs) have demonstrated that CVD risk markers, such as lipid parameters, inflammation markers, blood pressure, and arterial stiffness, are largely unaffected by vitamin D supplementation. Similar results have been obtained regarding CVD events and mortality from (meta)-analyses of RCTs, even in subgroups with 25(OH)D concentrations <50 nmol/l. Likewise, Mendelian randomization studies have indicated that the genetic reduction of the 25(OH)D concentration does not increase CVD risk. Some studies do not exclude the possibility of adverse vitamin D effects, such as elevated plasma calcium concentration and an increased CVD risk at a 25(OH)D concentration >125 nmol/l. Based on a conservative benefit-risk management approach, vitamin D doses beyond the nutritionally recommended amounts of 600 to 800 IE daily currently cannot be advised for the prevention of CVD events.

Analgesia Nociception Index Monitoring During Supratentorial Craniotomy.

Objective monitoring of pain during and after surgery has been elusive. Recently, Analgesia Nociception Index (ANI) monitor based on the high frequency component of heart rate variability has been launched into clinical practice. We monitored analgesia during craniotomy using ANI monitor and compared it with cardiovascular parameters and response entropy (RE) of entropy monitor. In 21 patients undergoing a craniotomy for a supratentorial lesion, we monitored ANI, heart rate (HR), mean arterial pressure (MAP), state entropy, and RE throughout the surgery. Also, ANI, hemodynamic variables and spectral entropy values were noted at the times of maximal stimulation, such as induction, intubation, head pin fixation, skin incision, craniotomy, durotomy, and skin closure. We also compared ANI with RE during administration of bolus doses of fentanyl. There was an inverse correlation between ANI values and the hemodynamic changes. When the HR and MAP increased, ANI decreased suggesting a good correlation between hemodynamics and ANI values during the times of maximal stimulation. State entropy and RE did not change significantly in response to bolus doses of fentanyl administered during the course of surgery, while ANI increased significantly. In neurosurgical patients undergoing elective supratentorial craniotomy, ANI measures response to noxious stimuli with at least as much reliability as hemodynamic variables and changes in ANI parallel the changes in HR and MAP. ANI is superior to RE for measurement of response to noxious stimuli.

Abstract 17166: Comparison Between Use of Vasoactive Medications in Patients Undergoing PVC and VT Ablation

Background: Societal guidelines have set prerequisites regarding procedures conducted in the EP lab. Despite metrics for management of EP cases, no clear guidelines exist for use of hemodynamic drugs to support complex ablations, particularly in setting of structural heart disease. Objectives: We sought to understand the variety and range of vasoactive medication use in patients undergoing PVC/VT ablation. Methods: Patients undergoing PVC or VT ablation, from January 2015 to December 2016, at our institution were analyzed. Demographics, echocardiography, and procedural details, including vasoactive medication use, were analyzed. Results: Sequential patients undergoing PVC or VT ablation (70 in each arm) were studied. Those undergoing PVC ablation (56 +/- 14 years, 30% female) had an average EF of 58% in comparison to 44% (p&lt;0.01 for EF difference) in VT ablation patients (60 +/- 13 years, 20% female); more VT patients (62%) were under general anesthesia. Pressors were administered in 86% of cases with the significant majority (63%) consisting of alpha-agonists (phenylephrine, ephedrine, epinephrine). Importantly, 48% of cases required continuous drip initiation (Figure). Regardless of case type or abnormal EF, drip initiation with or administration of multiple bolus doses of alpha-agonists was much more frequent compared to inotropes (Figure). In a subset of patients with EF ≤ 35%, 96% received vasoactive medications with 73% receiving a continuous drip or multiple bolus doses of phenylephrine. Conclusions: Vasoactive medication use during ventricular EP cases is common. Regardless of baseline EF, a propensity for use of alpha-agonists exists that may affect the treatment of patients with abnormal LV function. More studies are needed to assess the impact of pressor use on patient safety and procedural endpoints in the EP lab. Figure:

Novel Use of a Nurse-Led Telemedicine Team in Acute Stroke: A Retrospective Review of the Impact on a Regional Health Care System

IntroductionDespite the increasing incidence of acute ischemic stroke in the United States, many health care facilities remain unprepared to manage patients with acute stroke, including the administration of intravenous alteplase (recombinant tissue plasminogen activator [rTPA]). This has led to an opportunity for telemedicine systems to facilitate these evaluations and acute medical stroke treatment decisions. However, even telemedicine systems can fail to provide timely evaluation and management of the patient with acute stroke. The purpose of this retrospective study was to compare stroke outcome metrics pre- and postimplementation of a hybrid, local nurse-led “stroke-responder” telemedicine system. MethodsA retrospective chart review was performed on 21 patients at a regional community hospital between the years of 2014 and 2016. Data were collected pre- and postimplementation of a local stroke-responder system. Outcomes obtained included door-to-alert time, door-to-computerized tomography (CT) time, door-to-rtPA order time, and door-to-rtPA bolus dose administration time. Outcomes were compared among years. ResultsBetween 2014 and 2016, 21 charts were reviewed. Decreased mean times were observed for all metrics. The mean time for door-to-alert decreased from 21.19 to 5.84 minutes (P = 0.021), door-to-CT from 29.9 to 12.2 minutes (P = 0.022), door-to-rtPA order 88.4 to 53 minutes (P = 0.021), and door-to-rtPA administration from 106.94 to 64.65 minutes (P = 0.001). ConclusionIn an acute stroke telemedicine system, implementation of a local nurse-led “stroke responder” system resulted in significantly decreased acute stroke metrics for a community hospital within a regional hospital system.

Diagnostic Yield and Safety of Bronchoscopist-directed Moderate Sedation With a Bolus Dose Administration of Propofol During Endobronchial Ultrasound Bronchoscopy.

The propofol use for moderate sedation (MS) during endobronchial ultrasound (EBUS) bronchoscopy is primarily restricted for use by an anesthesiologist because of safety concerns. The goals of this study were to demonstrate the safety and the diagnostic yield of the use of propofol by bronchoscopists and trained endoscopy nurses during EBUS bronchoscopy without intubation. We tested a bolus propofol administration protocol targeting MS for EBUS bronchoscopy. A fixed initial dose of 40 mg of propofol along with a fixed 50 mcg fentanyl dose were administered. Sedation assessment was performed every 2 minutes, and repeated bolus doses of propofol were given to maintain MS under the direction of the bronchoscopist. A total of 122 subjects underwent EBUS bronchoscopy with a goal of MS from August 2015 to April 2017. In total, 110 subjects who underwent convex EBUS bronchoscopy under MS with propofol were included in the analysis. Median procedure duration was 57 minutes (range, 15 to 97 min). Deep sedation and agitation-related delay were occurred in 14 and 21 subjects, respectively. Hemodynamic instability and hypoxemia occurred in 23 subjects. However, there was no need for vasopressors or artificial airway placement. Median of total propofol dose per case was 560 mg. Diagnostic yield for malignancy and granuloma was 68%, and a median of 4 lymph node stations were sampled per subject. All specimens with adenocarcinoma were sufficient for genetic marker analysis. There were no major sedation-related complications. A bolus administration of propofol during EBUS bronchoscopy provided excellent adequacy of sedation and well tolerance safety profile.

The efficacy of elastomeric patient-control module when connected to a balloon pump for postoperative epidural analgesia: A randomized, noninferiority trial.

When considering the principles of a pain control strategy by patients, reliable administration of additional bolus doses is important for providing the adequate analgesia and improving patient satisfaction. We compared the efficacy of elastomeric patient-control module (PCM) with conventional PCM providing epidural analgesia postoperatively.A noninferiority comparison was used. Eighty-six patients scheduled for open upper abdominal surgery were randomized to use either an elastomeric or conventional PCM connected to balloon pump. After successful epidural catheter insertion at T6–8 level, fentanyl (15–20 μg/kg) in 0.3% ropivacaine 100 mL was administered at basal rate 2 mL/h with bolus 2 mL and lock-out time 15 minutes. The primary outcome was the verbal numerical rating score for pain.The 95% confidence intervals for differences in pain scores during the first 48 hours postoperatively were <1, indicating noninferiority of the elastomeric PCM. The duration of pump reservoir exhaustion was shorter for the elastomeric PCM (mean [SD], 33 hours [8 hours] vs 40 hours [8 hours], P = 0.0003). There were no differences in the frequency of PCM use, additional analgesics, or adverse events between groups.The elastomeric PCM was as effective as conventional PCM with and exhibited a similar safety profile.

Comparison of Pharmacokinetics of Enrofloxacin After Single Oral Bolus and Pulse Dose Administration in Broiler Chicken

Enrofloxacin was administered to commercial broiler chicken of 6 weeks of age at 10 mg kg−1 as oral bolus and pulse dose to two groups of twelve birds each. Blood was collected at predetermined time interval and plasma samples were analyzed for enrofloxacin concentration by using HPLC. Mean plasma concentration was significantly higher in oral bolus dose up to 2 h and at 48 h. In both the groups enrofloxacin concentration was above 0.30 μg mL−1 up to 24 h. Pharmacokinetic parameters were calculated by non compartmental analysis which revealed significant increase in AUC0–∞ (25.35 ± 1.92 vs. 19.66 ± 1.68 μg h mL−1) and t1/2β (10.63 ± 0.35 vs. 8.70 ± 0.74 h) in oral bolus dose when compared to pulse dose. There was no significant difference in other pharmacokinetic parameters such as MRT, MAT, Vd area/F, Vdss/F, ClB/F, Cmax and tmax. Hence it can be concluded that enrofloxacin administered to broiler chicken at 10 mg kg−1 every 24 h as pulse dose will result in better clinical efficacy at par with oral bolus dose.

Identifying a rapid bolus dose of dexmedetomidine (ED50) with acceptable hemodynamic outcomes in children.

Dexmedetomidine is a highly sensitive, specific α2 adrenoceptor agonist with anxiolytic, sedative, and analgesic effects. Administration is recommended as a loading dose infused over 10 min. Clinical experience and a previous study suggested a shorter time frame might be used without causing adverse hemodynamic effects. To determine the dexmedetomidine dose that can be given as a rapid 5 s bolus to healthy children during total intravenous anesthesia (TIVA) without causing significant hemodynamic effects. ASA I-II children, aged 5-9 years, having elective surgery under TIVA were recruited. The up-and-down sequential study design was employed to determine the effective dose of dexmedetomidine, starting at 0.3 mcg·kg(-1) with 0.1 mcg·kg(-1) intervals, which caused no hemodynamic response in half the subjects (ED50). Positive responses were defined as mean blood pressure (MAP) and/or heart rate (HR) changes ≥30% from baseline. Three parametric estimators and one nonparametric estimator were used to determine the ED50. Twenty-one subjects with median age 7.1 (range 5.4-9.5) years and median weight 23.6 (range 16.2-36.7) kg were recruited. A maximum median HR decrease of 20 b·min(-1) occurred at 50 s and a maximum median MAP increase of 12.5 mmHg occurred at 100 s after bolus dose administration. Fifteen subjects (71%) had a HR <60 b·min(-1) while one subject had a HR <40 b·min(-1) (minimum 35 b·min(-1)) for 60 s following the dexmedetomidine bolus. Four estimators led to an ED50 estimate for dexmedetomidine of 0.49 mcg·kg(-1) [95% CI 0.26-0.80 mcg·kg(-1)]. The ED50 of dexmedetomidine administered over 5 s without significant hemodynamic compromise is 0.49 mcg·kg(-1). Further work is needed to determine the 'safe' (ED5 or less) and effective dose for desired perioperative clinical outcomes.

A prospective, randomized study to evaluate the efficacy of various diuretic strategies in acute decompensated heart failure.

To evaluate the safety and efficacy of various initial strategies of loop diuretic administration in patients with acute decompensated heart failure (ADHF) on diuresis, renal function, electrolyte balance and clinical outcomes. Consecutive patients admitted with ADHF were randomized into three groups - intravenous furosemide infusion+intravenous dopamine, intravenous furosemide bolus in two divided doses and intravenous furosemide continuous infusion alone. At 48h, the treating physician could adjust the diuretic strategy. Primary endpoint was negative fluid balance at 24h after admission. Secondary end points were duration of hospital stay, negative fluid balance at 48, 72, 96h, the trend of serum electrolytes, and renal function and 30 day clinical outcome (death and emergency department visits). Overall ninety patients (thirty in each group) were included in the study. There was a greater diuresis in first 24h (p=0.002) and a shorter hospital stay (p=0.023) with the bolus group. There was no significant difference in renal function and serum sodium and serum potassium levels. There was no difference in the number of emergency department visits among the three groups. All three modes of diuretic therapies can be practiced with no difference in worsening of renal function and electrolyte levels. Bolus dose administration with itsrapid volume loss and shorter hospital stay might be a more effective diuretic strategy.

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Introduction: The pediatric intensive care unit changed its practice to deliver sedative bolus doses using 'smart' pump technology. Previously bolus doses required individual dose retrieval and preparation away from the patient bedside. Methods: Nursing staff were timed preparing and providing sedation boluses (fentanyl and midazolam) before (pre) and after (post) the utilization of 'smart' syringe pump technology. Data collected included; nurse time away from bedside; duration of bolus administration; amount of drug wastage and cost; frequency of central line access for bolus dose administration. Post-implementation nurse satisfaction and adverse event data was obtained via an online survey. Results: Fourteen nurses were timed giving and preparing 21 doses in the pre period and ten nurses were timed giving 19 doses in the post period. Nurse's time away from the bedside was reduced (p < 0.0001) and preparing the bolus doses were reduced (p < 0.0001). Slower more consistent bolus dosing were provided (p <0.0001). Drug wastage was reduced from 238.2 ± 162.4 mcg per patient day of fentanyl and 1.43 ± 1.44 mg per patient day of midazalam to zero wastage; this was a patient cost reduction of 78.4% for fentanyl and 58.5% for midazolam. Boluses via the pump reduced central line entries by 5.4 ± 2.9 per day. Nurses (n = 88) reported increased job satisfaction (93.2%), better patient pain control (90.9%). Conclusions: Utilizing 'smart' pump technology to administer sedation boluses improves nurse presence at bedside, consistency in practice, nurse job satisfaction and adherence to medication administration recommendations, and reduces medication wastage, cost to the patient, and frequency of central line access.

Optimization and characterization of a rat model of prostate cancer-induced bone pain using behavioral, pharmacological, radiological, histological and immunohistochemical methods

The major limitation of currently utilized rodent models of prostate cancer (PCa)-induced bone pain (PCIBP) involving intra-osseous injection of PCa cells, is their relatively short-term applicability due to progressive deterioration of animal health necessitating euthanasia. Here, we describe establishment of an optimized rat model of PCIBP where good animal health was maintained for at least 90-days following unilateral intra-tibial injection (ITI) of PCa cells. We have characterized this model using behavioral, pharmacological, radiological, histological and immunohistochemical methods. Our findings show that following unilateral ITI of 4×104 AT3B PCa cells (APCCs), there was temporal development of bilateral hindpaw hypersensitivity that was fully developed between days 14 and 21 post-ITI. Although there was apparent spontaneous reversal of bilateral hindpaw sensitivity that was maintained until at least day 90 post-ITI, administration of bolus doses of the opioid receptor antagonist, naloxone, rescued the pain phenotype in these animals. Hence, upregulation of endogenous opioid signaling mechanisms appears to underpin apparent spontaneous resolution of hindpaw hypersensitivity. Importantly, the histological and radiological assessments confirmed that tumor formation and development of osteosclerotic metastases was confined to the APCC-injected tibial bones. In our rat model of PCIBP, single bolus doses of morphine, gabapentin, meloxicam and amitriptyline produced dose-dependent relief of mechanical allodynia and thermal hyperalgesia in the bilateral hindpaws. The optimized rat model of PCIBP characterized herein has potential to provide new insights into the pathophysiological mechanisms associated with long-term (mal)adaptive pain due to advanced PCa-induced bony metastases and for screening novel compounds with potential for improved alleviation of this condition.