Dextrose In Water Research Articles

Intravenous fluid rate for reduction of cesarean delivery rate in nulliparous women: a systematic review and meta-analysis.

The National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine have emphasized the need to promote vaginal delivery and have offered recommendations to safely prevent primary cesarean delivery. However, there has been limited discussion regarding management of intravenous fluids and other aspects of labor management that may influence mode of delivery. Therefore the aim of our study was to determine whether an intravenous fluid rate of 250 vs. 125 mL/h is associated with a difference in cesarean delivery rate. Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov, the PROSPERO International Prospective Register of Systematic Reviews, Embase, Web of Science, and the Cochrane Library for randomized controlled trials. We included all randomized controlled trials comparing intravenous fluid rates of 250 vs. 125 mL/h in nulliparous women in spontaneous labor at term with singleton pregnancies at ≥36 weeks. Studies were included regardless of the type of intravenous fluids used and regardless of whether oral intake was restricted during labor. Studies including multiparous women or women whose labor was induced were excluded. The primary outcome was the incidence of cesarean delivery. We planned to assess a subgroup analysis according to type of fluids used and according to restriction of oral fluid intake. Seven trials including 1215 nulliparous women in spontaneous labor at term were analyzed; 593 (48.8%) in the 250 mL/h group, and 622 (51.2%) in the 125 mL/h group. Five studies used lactated Ringer's solution, one used normal saline in dextrose water, and in one study it was unclear which intravenous fluid was used. Women who received intravenous fluids at 250 mL/h had a significantly lower incidence of cesarean delivery for any indication (12.5 vs. 18.1%; RR 0.70, 95% CI 0.53-0.92; seven studies, 1215 participants; I2 = 0%) and for dystocia (4.9 vs. 7.7%; RR 0.60, 95% CI 0.38-0.97; five studies, 1093 participants; I2 = 18%), a significantly shorter mean duration of labor of about one hour (mean difference -64.38 min, 95% CI -121.88 to -6.88; six studies, 1155 participants; I2 = 83%) and a significantly shorter mean length of second stage of labor (mean difference -2.80 min, 95% CI -4.49 to -1.10; 899 participants; I2 = 22%) compared with those who received intravenous fluid at 125 mL/h. No differences were found in the other secondary outcomes. There were no maternal or perinatal deaths and only one woman, in the 125 mL/h group, developed pulmonary edema. The findings persisted regardless of the type of intravenous fluid used. No significant reduction in the incidence of cesarean delivery was demonstrated in women with unrestricted oral intake; however, this was limited to only two studies evaluating 254 women. Our findings provide evidence that the duration of labor in low-risk nulliparous women may be shortened by a policy of intravenous fluids at a rate of 250 mL/h rather than 125 mL/h. A rate of 250 mL/h seems to be associated with a reduction in the incidence of cesarean delivery compared to 125 mL/h. The number needed to treat to prevent one cesarean delivery is 18 women. Our data support increased hydration among nulliparous women in labor when oral intake is restricted. Further study is needed regarding risks and benefits of increased hydration among women with unrestricted oral intake, those undergoing induction of labor, and those with medical comorbidities.

Protective and Heat Retention Effects of Thermo-sensitive Basement Membrane Extract (Matrigel) in Hepatic Radiofrequency Ablation in an Experimental Animal Study.

To evaluate the protective effect of using thermo-sensitive basement membrane extract (Matrigel) for hydrodissection to minimize thermal injury to nearby structures and to evaluate its heat sink effect on the ablation zone in radiofrequency ablation (RFA) of the liver. First, the viscosity profile and heat sink effect of Matrigel were assessed during RFA in vitro and ex vivo. Fresh pig liver tissue was used, and the temperature changes in Matrigel and in 5% dextrose in water (D5W) during RFA were recorded. Then, the size of the ablation zone in the peripheral liver after RFA was measured. Second, in an in vivo study, 45 Sprague-Dawley rats were divided into three groups of 15 rats each (Matrigel, D5W and control). In the experimental groups, artificial ascites with 10ml of Matrigel or D5W were injected using ultrasound guidance prior to RFA. The frequency of thermal injury to the nearby organs was compared among the three groups, with assessments of several locations: near the diaphragm, the abdominal wall and the gastrointestinal (GI) tract. Finally, the biological degradation of Matrigel by ultrasound was evaluated over 60days. First, Matrigel produced a greater heat retention (less heat sink) effect than D5W during ex vivo ablation (63±9 vs. 26±6°C at 1min on the surface of the liver, P<0.001). Hepatic ablation zone volume did not differ between the two groups. Second, thermal injury to the nearby structures was found in 14 of 15 cases (93.3%) in the control group, 8 of 15 cases (53.3%) in the D5W group, and 1 of 15 cases (6.7%) in the Matrigel group. Significant differences in the thermal injury rates for nearby structures were detected among the three groups (P<0.001). The most significant difference in the thermal injury rate was found in locations near the GI tract (P=0.003). Finally, Matrigel that was injected in vivo was gradually degraded during the following 60days. Using thermo-sensitive Matrigel as a hydrodissection material might help reduce the frequency of collateral thermal injury to nearby structures, especially in locations close to the GI tract, compared to conventional D5W. Additionally, Matrigel did not increase the heat sink effect on the ablation zone during ablation and was degraded over time in vivo.

Compatibility of Ceftazidime-Avibactam, Ceftolozane-Tazobactam, and Piperacillin-Tazobactam with Vancomycin in Dextrose 5% in Water.

Objectives: The compatibility of vancomycin with existing and novel β-lactam/β-lactamase inhibitors at clinically relevant concentrations in 5% dextrose in water has not been fully explored to date. Methods: Vancomycin concentrations tested ranged from 5 to 20 mg/mL. Ceftazidime-avibactam was tested at 8, 20, and 40 mg/mL, ceftolozane-tazobactam at 15 mg/mL, and piperacillin-tazobactam at 28 mg/mL. Compatibility of drug admixtures were tested via both simulated and actual y-site infusion. For the simulated y-site compatibility assessment, 1:1 mixtures of each respective drug were analyzed over 24 hours. Actual y-site infusion followed a 4-hour extended-infusion protocol, with aliquots tested hourly for 4 hours. At all time points, the compatibility of each admixture was determined using 6 different methods: visual, microscopic, Tyndall beam, nephelometric, pH, and microbiologic bioassay assessment. If any admixture failed any one of these 6 assays, it was considered incompatible. Any combination deemed incompatible was filtered through a 0.22 μm filter and reanalyzed to assess impact of particle size. Results: There were no differences in compatibility categorizations between simulated and actual y-site infusion. There were no changes in compatibility over the time course of any experiment. Ceftazidime-avibactam at 8 mg/mL was incompatible with vancomycin at 5 mg/mL. The maximum compatible vancomycin concentrations were 5 mg/mL and 10 mg/mL with 20 and 40 mg/mL of ceftazidime-avibactam, respectively. Ceftolozane-tazobactam 15 mg/mL was compatible with vancomycin concentrations up to 10 mg/mL. The maximum compatible vancomycin concentration with piperacillin-tazobactam 28 mg/mL was 5 mg/mL. None of the β-lactam/β-lactamase inhibitors tested were compatible with 15 or 20 mg/mL of vancomycin. None of the admixtures considered incompatible by other methods displayed any decrease in antimicrobial activity as assessed by bioassay. After filtration, all admixtures originally deemed incompatible maintained their visual turbidity and microscopic particulate matter. Conclusions: Ceftazidime-avibactam prepared at the lowest concentration recommended in the package insert is incompatible with vancomycin. Ceftolozane-tazobactam did not display incompatibility until vancomycin concentrations above 10 mg/mL were tested. Piperacillin-tazobactam at a typical extended-infusion concentration is compatible with vancomycin in D5W. To our knowledge, this is the first study to assess compatibility of antibiotic admixtures via direct measurement of antimicrobial activity. The lack of any decrement in antibacterial activity of any apparently incompatible admixture and maintenance of incompatibility after passage through a 0.22 μm filter may suggest a lack of clinically relevant adverse effects when co-administered. Future compatibility studies should incorporate appropriate methods to accurately assess both efficacy and safety of co-administered drug products.

Extended Stability of Sodium Phosphate Solutions in Polyvinyl Chloride Bags.

Sodium phosphate injection is used to treat moderate to severe hypophosphatemia. There have been no published reports documenting the physical compatibility or chemical stability of sodium phosphate injection in IV solutions. To evaluate the physical compatibility and chemical stability of 30 and 150 mmol/L solutions of phosphate, prepared from sodium phosphate injection, in 5% dextrose in water (D5W) and in 0.9% sodium chloride (normal saline [NS]) and stored in polyvinyl chloride (PVC) bags at 23°C or 4°C over 63 days. On study day 0, solutions of phosphate 30 and 150 mmol/L in D5W or NS were prepared in PVC bags and stored at 4°C and 23°C. On prespecified days during the 63-day study period, the concentrations of sodium and phosphate were determined, and admixture weight was checked to assess moisture loss during storage without a plastic overwrap. Chemical stability was calculated from the intersection of the lower 95% confidence limit of the degradation rate and the lower limit of acceptability (90%) for concentration remaining. The analytical methods for both sodium and phosphate were found to be precise (coefficient of variation averaging less than 1% for pre-study validation samples). Both sodium and phosphate retained more than 94% of the initial concentration over the 63-day study period. With 95% confidence, the time to achieve 90% of the initial concentration of both sodium and phosphate approached or exceeded the 63-day study period, regardless of temperature, concentration, or base solution. Sodium phosphate solutions at a phosphate concentration of 30 or 150 mmol/L in either NS or D5W retained more than 94% of the initial concentration of both sodium and phosphate over 63 days when stored at 23°C or 4°C. In compliance with United States Pharmacopeia General Chapter <797> recommendations, a beyond-use date of 14 days (with refrigeration) or 48 h (room temperature) may be applied. Extending the beyond-use date beyond these limits may be considered, if a validated sterility test is performed.

Transition from Deep Regional Blocks toward Deep Nerve Hydrodissection in the Upper Body and Torso: Method Description and Results from a Retrospective Chart Review of the Analgesic Effect of 5% Dextrose Water as the Primary Hydrodissection Injectate to Enhance Safety.

Deep nerve hydrodissection uses fluid injection under pressure to purposely separate nerves from areas of suspected fascial compression, which are increasingly viewed as potential perpetuating factors in recalcitrant neuropathic pain/complex regional pain. The usage of 5% dextrose water (D5W) as a primary injectate for hydrodissection, with or without low dose anesthetic, could limit anesthetic-related toxicity. An analgesic effect of 5% dextrose water (D5W) upon perineural injection in patients with chronic neuropathic pain has recently been described. Here we describe ultrasound-guided methods for hydrodissection of deep nerve structures in the upper torso, including the stellate ganglion, brachial plexus, cervical nerve roots, and paravertebral spaces. We retrospectively reviewed the outcomes of 100 hydrodissection treatments in 26 consecutive cases with a neuropathic pain duration of 16 ± 12.2 months and the mean Numeric Pain Rating Scale (NPRS) 0–10 pain level of 8.3 ± 1.3. The mean percentage of analgesia during each treatment session involving D5W injection without anesthetic was 88.1% ± 9.8%. The pretreatment Numeric Pain Rating Scale score of 8.3 ± 1.3 improved to 1.9 ± 0.9 at 2 months after the last treatment. Patients received 3.8 ± 2.6 treatments over 9.7 ± 7.8 months from the first treatment to the 2-month posttreatment follow-up. Pain improvement exceeded 50% in all cases and 75% in half. Our results confirm the analgesic effect of D5W injection and suggest that hydrodissection using D5W provides cumulative pain reduction.

Transition from Deep Regional Blocks toward Deep Nerve Hydrodissection in the Upper Body and Torso. Method Description and Results from a Retrospective Chart Review of the Analgesic Effect of 5% Dextrose in Water (D5W) as the Primary Hydrodissection

Although low-level studies demonstrate effectiveness of nerve hydrodissection, there are no high level studies to date.4 Prior to high-level study performance, procedural methods must be described that are reproducibly performed, reliable in effect, and safe. The objectives of this article are to illustrate reproducible methods of hydrodissection for upper torso deep nervous structures including the stellate ganglion, brachial plexus, cervical nerve roots and paravertebral spaces, and to gather preliminary data related to an analgesic effect and efficacy of D5W without lidocaine as the primary injectate in hydrodissection for those conditions. A formal letter of exemption allowing retrospective chart review was obtained from the International Cellular Medicine Society Institutional Review Board. (ICMS-IRB). Consecutive charts were reviewed for patients who received hydrodissection of stellate ganglion, brachial plexus, cervical nerve roots, or paravertebral spaces as a treatment method for neuropathic pain, using D5W exclusively, with lidocaine used for skin blebs only. Chart selection continued until data from 100 treatments was available for analysis. Methods of hydrodissection utilized on patients in this consecutive patient data collection were illustrated with use of anatomical diagrams, ultrasound images and videos. The primary measure for a potential intraprocedural analgesia effect of D5W hydrodissection was the mean difference between pre-treatment pain and immediate (5 minute) post-treatment pain in points as measured on a 0-10 Numerical Rating Scale (NRS). The patients were followed-up at two-month post-treatment to inquire about further need for treatment and to obtain a final 0-10 NRS pain level to monitor for treatment efficacy. Data were analyzed using PASW 18 (Predictive Analytics 180 Software 18.0.0, IBM). Descriptive statistics (mean ± standard deviation) were reported at baseline and at each session for NRS. Cumulative improvement in patient’s pain levels over time was determined by calculating the mean difference between pre-treatment patient pain measured at time 0 and post-treatment pain measured 2 months after the last clinic visit. The percentage of cases achieving more than 50% and more than 75% improvement in pain was calculated. A retrospective chart review was performed of treatment results from 100 hydrodissection treatments in 26 consecutive cases (25 patients; one receiving treatment bilaterally) 51±14.7 years of age, with neuropathic pain duration of 16±12.2 months and initial numerical rating scale for pain (NRS 0-10) of 8.3±1.3 points. The mean percentage of analgesia during each treatment session was 88.1±9.8% with injection of D5W without anesthetic. NRS pain levels changed from 8.3±1.3 pre-treatment to 1.9±0.9 two months after the last treatment for a point change improvement of 6.4±1.7 points. Patients received 3.8±2.6 treatments over 9.7±7.8 months from 1st treatment to 2-month-post-treatment follow-up. Pain improvement exceeded 50% in all cases and 75% in half (13/26). An analgesic effect of D5W injection is confirmed by this study and a cumulative pain reduction is suggested. This article has illustrated potentially-reproducible methods of hydrodissection for stellate ganglion, brachial plexus, cervical nerve roots and paravertebral spaces, provides data supporting a consistent analgesic effect of D5W and suggests a potentially sustainable clinical benefit in patients with chronic upper back/thorax pain of neuropathic origin. The mechanism of analgesia may relate to an indirect (allosteric) effect on the TRPV1 cation channel, hyperpolarization of normoglycemic C fibers, correction of local neural hypoglycemia, or undiscovered, likely multiple, mechanisms. The well-developed chronic constriction injury model, which results in neuropathic pain and neural swelling, is the primary rationale behind hydrodissection of nerves to release the nerve from suspected local neural compression, particularly for those nerves with fascicular nerve swelling or an increase in overall neural volume. The frequency of neural edema and the long-term efficacy of nerve hydrodissection in neuropathic pain, in contrast to anesthetic low volume nerve block, are important foci of future research in neuropathic pain conditions.

Adding 5% Dextrose Water to Bupivacaine in Ultrasound-Guided Axillary Brachial Plexus Block

Adding 5% Dextrose Water to Bupivacaine in Ultrasound-Guided Axillary Brachial Plexus Block

Hypocalcaemia, Hypoglycaemia, Macrosomia and Congenital Cryptorchidism in a Male Offspring of a Mother with Overweight and Gestational Diabetes Mellitus

AbstractThis paper reports a case of a male infant born to a 32-year-old multiparous mother with overweight (BMI 28.5kg/m2) and gestational diabetes mellitus (GDM). The mother had fasting hyperglycaemia (range 5.7- 6.0mmol/L) noted at 24 weeks of pregnancy and was managed with diet alone. There is no family history of diabetes mellitus and the mother did not have pre-eclampsia. Physical examination of the infant revealed macrosomia (birthweight, 4600g) and bilateral congenital cryptorchidism. The baby suffered severe hypoglycaemia (blood glucose 1.7mmol/L) and hypocalcaemia (total serum calcium 1.03mmol/L), manifesting with seizures. He was successfully managed with 10% dextrose water and calcium gluconate infusion, using standard protocol. His karyotype is 46 XY. The patient was discharged from admission at the age of 10 days and was referred to the paediatric endocrinologist at the tertiary hospital. By 8 weeks of age, the right testis was noticed to have descended into the right scrotum. At the age of 3 months, the left testis was still not palpable either in the inguinal canal or the scrotal sac. The patient was lost to follow up. Conclusion: Diet-treated maternal overweight in association with GDM could potentially increase the risk for hypocalcaemia, hypoglycaemia, macrosomia and congenital cryptorchidism in the offspring, highlighting the need for physicians to assess for the presence of these morbidities in such infants.

Furosemide continuous rate infusion diluted with 5% dextrose in water or hypertonic saline in normal adult dogs: a pilot study

ObjectiveThe goal of this study was to investigate the short-term safety and diuretic efficacy of furosemide constant rate infusion (CRI) diluted with 5% dextrose in water (D5W) compared to dilution with 2.4% hypertonic saline in healthy dogs. AnimalsSix healthy dogs. MethodsDogs were studied in a randomized, blinded, crossover manner. Furosemide 3.3mg/kg was diluted to 2.2mg/mL with either 1.5mL/kg D5W for the DEX method or with 1.0mL/kg D5W and 0.5mL/kg of 7.2% hypertonic saline for the H-SAL method. After a 0.66mg/kg furosemide IV bolus, the infusion rate was 0.3 mL/kg/hr for 5 h such that both methods delivered 0.66 mg/kg/hr (total 3.3mg/kg) furosemide in equal volume for the study duration. Urine output, water intake, central venous pressure (CVP), physical parameters, furosemide concentrations, blood and urine electrolytes, and urine aldosterone to creatinine ratio (UAldo:C) were evaluated. ResultsMeasured variables were not different between methods but showed changes over time consistent with diuresis. Mean CVP decreased over time similarly for both methods. Plasma furosemide and urine concentrations were stable and not different between methods. Both furosemide CRI methods showed an increase in the UAldo:C, however, the rise was greater for DEX than for H-SAL. ConclusionsDiuresis was similar for both furosemide CRI methods; however, the H-SAL method induced less renin-angiotensin-aldosterone system activation than the DEX method. The absence of intravascular volume expansion based on CVP suggests that dilution of a furosemide CRI with 2.4% hypertonic saline may be well tolerated in heart failure.

Five percent dextrose maximizes dose delivery of Yttrium-90 resin microspheres and reduces rates of premature stasis compared to sterile water.

Resin Yttrium-90 (Y90) microspheres have historically been infused using sterile water (H2O). In 2013, recommendations expanded to allow delivery with 5% dextrose in water (D5W). In this retrospective study, we hypothesized that D5W would improve Y90 delivery with a lower incidence of stasis. We reviewed 190 resin Y90 infusions using H2O (n=137) or D5W (n=53). Y90 dosimetry was calculated using the body surface area method. Infusion was halted if intra-arterial stasis was fluoroscopically identified prior to clearing the vial. Differences between H2O and D5W groups were calculated for activity prescription, percentage of cases reaching stasis, and percentage delivery of prescribed activity using z- and t-test comparisons, with α=0.05. Thirty-one of 137 H2O infusions developed stasis compared to 2 of 53 with D5W (z=3.07, p=1.05E-03). D5W also had a significantly higher prescribed activity than H2O [28.2 millicuries (mCi) vs. 20.4 mCi, respectively; t=5.0, p=1.1E-6]. D5W had a higher delivery percentage of the prescribed dose compared to H2O (101.5 vs. 92.7%, respectively; t=3.8, p=1.92E-4). In conclusion, resin microsphere infusion utilizing D5W has a significantly lower rate of stasis than H2O and results in more complete dose delivery. D5W is preferable to H2O for resin microsphere infusion.

A novel intravenous vehicle for preclinical cardiovascular screening of small molecule drug candidates in rat

Screening novel, poorly soluble small-molecule candidates for cardiovascular liabilities represents a key challenge in early drug discovery. This report describes a novel vehicle composed of 20% N,N-Dimethylacetamide (DMA)/40% Propylene glycol (PG)/40% Polyethylene Glycol (PEG-400) (DPP) for administration of new chemical entities (NCEs) by slow intravenous (i.v.) infusion in a preclinical anesthetized rat model. The vehicle was designed considering both available excipient safety information and solubilization potential for poorly soluble NCEs. DPP solubilized 11 drugs, 8 of which were insoluble in 5% dextrose in water (D5W), and 5 insoluble in PEG-400 to a target concentration of 30mg/mL. DPP elicits no adverse cardiovascular responses in the anesthetized rat model despite containing 40% PEG-400, a commonly used organic solvent which elicits hypertension and bradycardia that often confounds interpretation of drug effects. Three compounds demonstrating adequate solubility in both DPP and D5W were screened in the anesthetized rat model. When normalized to plasma exposure, atenolol, sotalol and enalaprilat exhibited comparable mean arterial pressure, heart rate, and cardiac contractility responses regardless of formulation. While the antihypertensive effect of nifedipine was evident with both DPP and PEG-400 formulations, pressor effects from PEG-400 confounded interpretation of the magnitude of nifedipine's response. Plasma concentrations of atenolol and enalaprilat were greater in D5W formulation whereas sotalol exposures were greater when using DPP as a vehicle. These results demonstrate the utility of DPP as an intravenous vehicle for formulating poorly soluble compounds in early preclinical screening for cardiovascular safety studies.

Fungal bioremediation of olive mill wastewater: using a multi-step approach to model inhibition or stimulation.

Olive mill wastewaters (OMWWs) possess a strong environmental impact; the use of fungi as tools for bioremediation could be a promising method. Twenty-nine fungi were grown on minimal media supplemented with five different kinds of OMWWs (5-15%). Radial growth was assessed for 21 days and the data were modelled through the Dantigny-logistic like function to estimate τ, i.e. the time to attain half of the maximum diameter. Growth on potato dextrose agar and water agar (WA, minimal medium without supplementation) was used as reference. The differences in τ between PDA/WA and minimal media with OMWWs were modelled through a multi-factorial ANOVA, using the concentration of OMWW, the kind of wastes and fungi as categorical predictors. Finally, a principal component analysis was run to group and divide resistant and sensitive fungi. Some fungi experienced a positive Δτ, thus suggesting an inhibition by OMWW, whereas other isolates were enhanced. Some isolates (for example Aspergillus ochraceus) showed a promising trend and could be possible candidates for a validation on a real scale. © 2016 Society of Chemical Industry.

We Do It for Our Patients.

We Do It for Our Patients.

Safety of intravitreal quinupristin/dalfopristin in an animal model.

To determine whether different intravitreal doses of quinupristin/dalfopristin lead to electroretinographic or histological changes in the rabbit retina over one month period after injection. Eighteen New Zealand white rabbits were divided into three treatment groups (groups 1 to 3) and different intravitreal doses of quinupristin/dalfopristin were tested in each group. The right eye was injected with the drug and the left eye received intravitreal injection of 5% dextrose water and served as control eye. The doses delivered to each group were 0.1 mg/0.1 mL, 1 mg/0.1 mL and 10 mg/0.1 mL. Simultaneous, bilateral, dark-adapted electroretinography and clinical images of both eyes were obtained in all groups before injection (baseline) and after 7, 14, 21 and 28d, followed by enucleation for histological examination. Subjects in the group 1 showed no signs of toxicity in the electroretinogram when compared with groups 2 and 3 (Kruskall-Wallis test, P=0.000). By day 7, no electrical response to light stimuli was recorded in the treated eyes in groups 2 and 3, consistent with severe damage due to retinal toxicity. Light microscopy revealed no significant histopathological changes in the group 1, while rabbits in groups 2 and 3 had signs of granulomatous inflammation in most cases. Intravitreal 0.1 mg/0.1 mL doses of quinupristin/dalfopristin do not lead to electroretinographic or histological signs of retinal toxicity compared with 1 mg/0.1 mL and 10 mg/0.1 mL in this rabbit model.

Evaluation of two injection sclerosants in the treatment of symptomatic haemorrhoids in Nigerians.

The objective of this study was to compare the efficacy and safety of 5% phenol in almond oil with 50% dextrose water as sclerosants in the treatment of first- to third-degree haemorrhoids. This was a prospective, comparative study conducted on eighty patients with first-, second- and third-degree haemorrhoids who consented to treatment by injection sclerotherapy with either 5% phenol in almond oil or 50% dextrose water. They were randomised equally into two groups. A total of eighty patients including 58 males and 22 females whose age ranged from 19 to 61 years were included in the study. Bleeding was the chief symptom which was present in 78 (97.5%) patients, and there was complete resolution of this in 92.3% and 89.7% in the 5% phenol in almond oil and 50% dextrose water groups, respectively, at 6 months (P = 0.905). Similar degrees of resolution were noted for anal protrusion (89.1% and 85.3% in the 5% phenol in almond oil and 50% dextrose water group, respectively, P = 0.899). The overall complication rate was 3.6% with anal mucosa ulceration being the only complication, occurring in three patients who had 5% phenol in almond oil. Peri-procedure pain, patients satisfaction and acceptability were not significantly different in both groups (P = 0.912, 0.928 and 0.926 respectively). Five percent phenol in almond oil and 50% dextrose water are equally effective sclerosants in the treatment of haemorrhoids with very low complication rates.

High Opening Injection Pressure Is Associated With Needle-Nerve and Needle-Fascia Contact During Femoral Nerve Block.

High opening injection pressures (OIPs) have been shown to predict sustained needle tip contact with the roots of the brachial plexus. Such roots have a uniquely high ratio of fascicular versus connective tissue. It is unknown if this relationship is preserved during multifascicular nerve blockade. We hypothesized that OIP can predict needle-nerve contact during femoral nerve block, as well as detect needle contact with the fascia iliaca. Twenty adults scheduled for femoral block were recruited. Using ultrasound, a 22-gauge needle was sequentially placed in 4 locations: indenting the fascia iliaca, advanced through the fascia iliaca while lateral to the nerve, slightly indenting the femoral nerve, and withdrawn from the nerve 1 mm. At each location, the OIP required to initiate an injection of 1 mL D5W (5% dextrose in water) at 10 mL/min was recorded. Blinded investigators performed evaluations and aborted injections when an OIP of 15 psi was reached. Opening injection pressure was 15 psi or greater for 90% and 100% of cases when the needle indented the femoral nerve and fascia iliaca, respectively. Opening injection pressure was less than 15 psi for all 20 patients when the needle was withdrawn 1 mm from the nerve as well as at the subfascial position (McNemar χ2 P < 0.001). Opening injection pressure greater than 15 psi was associated with a block needle tip position slightly indenting the epineurium of the femoral nerve (90%) and the fascia iliaca (100%). Needle tip positions not indenting these structures were associated with OIP of less than 15 psi (100%).

Licorice versus ketamine gargle for postoperative sore throat due to insertion of a double-lumen endobronchial tube

Background Postoperative sore throat (POST) is common after tracheal intubation, especially with double-lumen endobronchial tube (DLT). Licorice has many uses such as dental hygiene and in sore throat. Ketamine gargle is a newly proposed adjunct for reducing the incidence of POST in anesthesia. The aim of this study was to determine the efficacy of licorice and ketamine gargles in patients undergoing the insertion of DLT in preventing POST within 24 h. Methods This prospective, randomized, double-blind study included 90 patients undergoing thoracic surgery requiring DLT for one-lung ventilation. Patients were randomized to three groups (n=30) and were asked to gargle for 1 min to 15 min before operations. Group A received ketamine gargle (0.5 mg/kg ketamine in 30 ml of dextrose water 20%), group B received licorice gargle (500 mg licorice powder in 30 ml of dextrose water 20%), and group C (the control group) received 30 ml of dextrose water 20% gargle. Assessment of patients for the incidence and the severity of POST and any side effect was carried out in the recovery room. Sore throat (yes/no) and severity of its pain measured using visual analogue scale were recorded at baseline in the recovery room and then at 2, 4, and 24 h after operation with a specified questionnaire. Results The incidence of sore throat was significantly higher in group C at all time points in comparison with the other two groups. There was a marked decrease in the incidence of sore throat in groups A and B, with no significant difference between them. The severity of POST pain was significantly higher in group C when compared with the other two groups, with no significant difference between them and with no complications. Conclusion Ketamine and licorice gargles decrease the incidence and severity of sore throat occurring postoperatively due to DLT intubation, with no significant differences between them.

Unrecognised Free Water Loss in a Patient with Lithium-Induced Nephrogenic Diabetes Insipidus Can Cause Acute Kidney Injury and Near Fatal Hypernatremia...

Lithium is the commonest cause of drug induced nephrogenic diabetes insipidus (NDI) [1], a condition in which the patient passes large amounts of dilute urine due to the kidney’s loss of the ability to concentrate the urine in response to anti diuretic hormone (ADH). Affected patients may satisfy their polydipsia and avoid dehydration and hyper natremia if they have access to water, but severe hypernatremia can develop if they become acutely unwell or if oral intake of water is restricted. We report a patient on long -term lithium therapy for bipolar disorder who presented with severe confusion, dysarthria and disorientation, and subsequently developing severe hyper natremia and coma despite intravenous saline infusions. She was intubated and ventilated and successfully treated with initial volume expansion and subsequently with intravenous 5% dextrose in water.

Reference Change Values for Sodium Are Ignored by the American and European Treatment Guidelines for Hyponatremia

Updated revised expert panel recommendations on the evaluation and treatment of hyponatremia were published in the United States in 2013 (1). In 2014, a separate set of guidelines were issued by a group representing the European Society of Intensive Care Medicine, the European Society of Endocrinology, and the European Renal Association–European Dialysis and Transplant Association represented by European Renal Best Practice (2). The recommended rates of correction of chronic hyponatremia from the US group are 4–8 mmol/L per day for patients at low risk of osmotic demyelinating syndrome (ODS)4 and 4–6 mmol/L per day if that risk is high. The limits not to exceed are 8 mmol/L in any 24-h period when the ODS risk is high, and when the ODS risk is low, 10–12 mmol/L in any 24-h period and 18 mmol/L in any 48-h period. If 8 mmol/L is exceeded in a 24-h period, there should be no active therapeutic intervention for the next 24 h (1). Regarding frequency of sodium analysis, serum sodium should be measured at 4- to 6-h intervals until mildly hyponatremic concentrations ≥125 mmol/L have been reached. The section on counteracting overcorrection of chronic hyponatremia by >6–8 mmol/L in the first 24 h of therapy discusses the uses of 2–4 μg desmopressin with repeated 3-mL/kg infusions of 5% dextrose in water administered over 1 h combined with the measurement of serum sodium after each infusion, i.e., hourly until the therapeutic target for the patient has been reached when the starting serum sodium is <120 mmol/L. When using vasopressin receptor antagonists (vaptans) and when treating diuretic-induced hyponatremia, measurements of serum sodium are set at a 6- to 8-h minimum until a stable sodium value >125 mmol/L has been reached. When diuretics have caused hyponatremia-induced seizures, hypertonic saline is recommended to raise the …

The Effect of Radiation Dose and Variation in Neupogen® Initiation Schedule on the Mitigation of Myelosuppression during the Concomitant GI-ARS and H-ARS in a Nonhuman Primate Model of High-dose Exposure with Marrow Sparing.

A nonhuman primate (NHP) model of acute high-dose, partial-body irradiation with 5% bone marrow (PBI/BM5) sparing was used to assess the effect of Neupogen® [granulocyte colony stimulating factor (G-CSF)] to mitigate the associated myelosuppression when administered at an increasing interval between exposure and initiation of treatment. A secondary objective was to assess the effect of Neupogen® on the mortality or morbidity of the hematopoietic (H)- acute radiation syndrome (ARS) and concurrent acute gastrointestinal radiation syndrome (GI-ARS). NHP were exposed to 10.0 or 11.0 Gy with 6 MV LINAC-derived photons at approximately 0.80 Gy min. All NHP received medical management. NHP were dosed daily with control article (5% dextrose in water) initiated on day 1 post-exposure or Neupogen® (10 μg kg) initiated on day 1, day 3, or day 5 until recovery [absolute neutrophil count (ANC) ≥ 1,000 cells μL for three consecutive days]. Mortality in both the 10.0 Gy and 11.0 Gy cohorts suggested that early administration of Neupogen® at day 1 post exposure may affect acute GI-ARS mortality, while Neupogen® appeared to mitigate mortality due to the H-ARS. However, the study was not powered to detect statistically significant differences in survival. The ability of Neupogen® to stimulate granulopoiesis was assessed by evaluating key parameters for ANC recovery: the depth of nadir, duration of neutropenia (ANC < 500 cells μL) and recovery time to ANC ≥ 1,000 cells μL. Following 10.0 Gy PBI/BM5, the mean duration of neutropenia was 11.6 d in the control cohort vs. 3.5 d and 4.6 d in the day 1 and day 3 Neupogen® cohorts, respectively. The respective ANC nadirs were 94 cells μL, 220 cells μL, and 243 cells μL for the control and day 1 and day 3 Neupogen® cohorts. Following 11.0 Gy PBI/BM5, the duration of neutropenia was 10.9 d in the control cohort vs. 2.8 d, 3.8 d, and 4.5 d in the day 1, day 3, and day 5 Neupogen® cohorts, respectively. The respective ANC nadirs for the control and day 1, day 3, and day 5 Neupogen® cohorts were 131 cells μL, 292 cells μL, 236 cells μL, and 217 cells μL, respectively. Therefore, the acceleration of granulopoiesis by Neupogen® in this model is independent of the time interval between radiation exposure and treatment initiation up to 5 d post-exposure. The PBI/BM5 model can be used to assess medical countermeasure efficacy in the context of the concurrent GI- and H-ARS.