Parenteral Medication Research Articles

Intravenous Droperidol or Olanzapine as an Adjunct to Midazolam for the Acutely Agitated Patient: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Clinical Trial

Parenteral benzodiazepines or antipsychotics are often used to manage acute agitation in emergency department (ED) settings in which alternative strategies have failed or are not feasible. There are scant data comparing parenteral medication regimens. We aim to determine the efficacy and safety of intravenous droperidol or olanzapine as an adjunct to intravenous midazolam for rapid patient sedation. We undertook a randomized, double-blind, placebo-controlled, double-dummy, clinical trial in 3 EDs (August 2009 to March 2011). Adult patients (n=336) requiring intravenous drug sedation for acute agitation were randomized to receive a saline solution (control), droperidol (5 mg), or olanzapine (5 mg) bolus. This was immediately followed by incremental intravenous midazolam boluses (2.5 to 5 mg) until sedation was achieved. The primary outcome was time to sedation. Secondary outcomes were need for "rescue" drugs and adverse events. Three hundred thirty-six patients were randomized to the 3 groups. Baseline characteristics were similar across groups. The differences in medians for times to sedation between the control and droperidol and control and olanzapine groups were 4 minutes (95% confidence interval [CI] 1 to 6 minutes) and 5 minutes (95% CI 1 to 6 minutes), respectively. At any point, patients in the droperidol and olanzapine groups were approximately 1.6 times more likely to be sedated compared with controls: droperidol and olanzapine group hazard ratios were 1.61 (95% CI 1.23 to 2.11) and 1.66 (95% CI 1.27 to 2.17), respectively. Patients in the droperidol and olanzapine groups required less rescue or alternative drug use after initial sedation. The 3 groups' adverse event profiles and lengths of stay did not differ. Intravenous droperidol or olanzapine as an adjunct to midazolam is effective and decreases the time to adequate sedation compared with midazolam alone.

RETRACTED: Central venous catheterization and thrombosis in newborns: update on diagnosis and management

RETRACTION

Perioperative Hypertension: Defining At-Risk Patients and Their Management

Hypertension is an extremely pervasive condition that affects a large percentage of the world population. Although guidelines exist for the treatment of the patient with elevated blood pressure, there remains a paucity of literature and accepted guidelines for the perioperative evaluation and care of the patient with hypertension who undergoes either cardiac or noncardiac surgery. Of particular importance is defining the patients most vulnerable to complications and the indications for immediate and rapid antihypertensive treatment and/or cancellation of surgery to reduce these risks in each of the three perioperative settings: preoperative, intraoperative, and postoperative. This review also examines the parenteral antihypertensive medications most commonly administered in the perioperative setting.

THERAPY IN ENDOCRINE DISEASE: Etomidate in the management of hypercortisolaemia in Cushing's syndrome: a review

This review addresses the practical usage of intravenous etomidate as a medical therapy in Cushing's syndrome. We reviewed the relevant literature, using search terms ‘etomidate’, ‘Cushing's syndrome’, ‘adrenocortical hyperfunction’, ‘drug therapy’ and ‘hypercortisolaemia’ in a series of public databases. There is a paucity of large randomised controlled trials, and data on its use rely only on small series, case study reports and international consensus guideline recommendations. Based on these, etomidate is an effective parenteral medication for the management of endogenous hypercortisolaemia, particularly in cases with significant biochemical disturbance, sepsis and other serious complications such as severe psychosis, as well as in preoperative instability. We suggest treatment protocols for the safe and effective use of etomidate in Cushing's syndrome.

Evaluation of Atropine 1% Ophthalmic Solution Administered Sublingually for the Management of Terminal Respiratory Secretions

Terminal respiratory secretions (TRS) or "death rattle" is a common symptom in the dying patient. Current practice for the prevention and treatment of TRS involves the use of oral, sublingual, transdermal, or parenteral anticholinergic medications. A retrospective chart review of patients admitted to a hospice inpatient unit for terminal care and treated with sublingual atropine 1% ophthalmic drops for TRS was conducted. A total of 19 of 22 patients treated with atropine had documented reduction or resolution of TRS. This study suggests that atropine 1% ophthalmic drops administered sublingually are a reasonable option for the management of TRS. Problematic cardiac or central nervous system symptoms were not found in the present study. Results should aid hospice programs who are seeking guidance on the management of TRS with atropine 1% ophthalmic drops.

Basic-Level Emergency Medical Technician Administration of Fluids and Glucose via Enzyme-Assisted Subcutaneous Infusion Access

During disasters and mass-casualty incidents (MCIs), there may be insufficient numbers of advanced life support (ALS) providers to provide intravenous (IV) access to all patients requiring parenteral fluids and/or medications. Enzyme-assisted subcutaneous infusion (EASI) access, in which human recombinant hyaluronidase (HRH) augments subcutaneous fluid dispersion and absorption, may be useful when ALS resources are insufficient to meet intravascular access needs. The utility of the use of the EASI lies, in part, in its ease of placement by ALS personnel. The objectives of this study were to document the feasibility, comfort, and speed/degree of infused-glucose uptake through EASI lines placed by basic-level emergency medical technicians (EMT-Bs). Eighteen EMT-Bs instituted EASI access on each other. A total of 150 units (1 mL) of HRH were administered through the EASI line, followed by the administration of 250 mL of tracer-labeled D5W. Timed phlebotomy enabled gas chromatography/mass spectrometry characterization of glucose uptake. Enzyme-assisted subcutaneous infusion placement and comfort ratings were tracked and analyzed using non-parametric statistics and Fisher's Exact Test. In all 18 subjects, EASI access required only one attempt and was rated by the EMT-Bs as easy to accomplish. Glucose was absorbed quickly (within five minutes) in all subjects. The rate of infusion was rapid (median 393 mL/hour) and was comfortable for the recipients (median pain score 1/10). The use of EASI may be viable as a fast, simple, and reliable method for the administration of fluid and glucose by EMT-Bs.

Parenteral medication preparation by pharmacy technicians on the ward improves medication safety

BackgroundPreparation of parenteral medications is associated with considerable risk that is medication errors and risk of microbiological contamination. In Dutch hospitals parenteral medications are commonly prepared on the ward by...

Toxicity with radiotherapy for oral cancers and its management: A practical approach

Radiotherapy-induced damage in the oral mucosa is the result of the deleterious effects of radiation, not only on the oral mucosa itself but also on the skin, adjacent salivary glands, bone, dentition, and masticatory apparatus. From basic skin care to dental and oral health maintenance, several ointments and lotions, oral and parenteral medications, biological response modifiers, cytoprotective drugs, newer radiation techniques and surgery have been introduced to combat and more importantly to prevent the development of these complications. Radiotherapy-induced oral complications involve complex and dynamic pathobiological processes. This in the immediate- and long-term course lowers the quality of life and predisposes patients to serious clinical disorders. Here, we focus on these oral complications of radiotherapy, highlight preventive and therapeutic developments, and review the current treatment options available for these disorders.

How Frequently are "Classic" Drug-Seeing Behaviors used by Drug-Seeking Patients in the Emergency Department?

Introduction:Drug-seeking behavior (DSB) in the emergency department (ED) is a very common problem, yet there has been little quantitative study to date of such behavior. The goal of this study was to assess the frequency with which drug seeking patients in the ED use classic drug seeking behaviors to obtain prescription medication.Methods:We performed a retrospective chart review on patients in an ED case management program for DSB. We reviewed all visits by patients in the program that occurred during a 1-year period, and recorded the frequency of the following behaviors: complaining of headache, complaining of back pain, complaining of dental pain, requesting medication by name, requesting a refill of medication, reporting medications as having been lost or stolen, reporting 10/10 pain, reporting greater than 10/10 pain, reporting being out of medication, and requesting medication parenterally. These behaviors were chosen because they are described as “classic” for DSB in the existing literature.Results:We studied 178 patients from the case management program, who made 2,486 visits in 1 year. The frequency of each behavior was: headache 21.7%, back pain 20.8%, dental pain 1.8%, medication by name 15.2%, requesting refill 7.0%, lost or stolen medication 0.6%, pain 10/10 29.1%, pain greater than 10/10 1.8%, out of medication 9.5%, and requesting parenteral medication 4.3%. Patients averaged 1.1 behaviors per visit.Conclusion:Drug-seeking patients appear to exhibit “classically” described drug-seeking behaviors with only low to moderate frequency. Reliance on historical features may be inadequate when trying to assess whether or not a patient is drug-seeking.

Relapse of Intravenous Drug Use Triggered by Enfuvirtide, a Parenteral Antiretroviral Medication

Fuzeon® (enfuvirtide; Hoffmann-LaRoche, Nutley, NJ) is a parenteral medication prescribed to antiretroviral-experienced HIV patients. Clinicians are frequently concerned when prescribing enfuvirtide to former drug addicts because of the risk of triggering relapse, however, no previous report has described this adverse event. We describe two HIV-infected patients, previously abstinent from injection drug use, who experienced relapse or near-relapse situations after starting treatment with enfuvirtide. Along with the concerns related to adherence and to injection site reactions, clinicians who prescribe enfuvirtide should consider and discuss the risk of triggering relapse among former or recovering drug addicts.

Intestinal Mucormycosis in Crohnʼs Disease

Purpose: Mucormycosis is a rare fungal infection. Immunocompromised individuals may become infected with exposure to airborne spores. We present a rare case of gastrointestinal mucormycosis after treatment with corticosteroids in the setting of inflammatory bowel disease. A 38-year-old Caucasian female recently diagnosed with Crohn's disease presented to a local hospital with 9 months history of abdominal pain and diarrhea. Colonoscopy revealed moderately severe ulcerative ileocolonic Crohn's disease. She was placed on 40mg oral prednisone and mesalamine 3.2gm daily by her primary gastroenterologist. She had been smoking one and half packs of cigarettes. She continued prednisone 40mg for two months, when she presented to our facility with worsening of abdominal pain, hypotension and sepsis. CT scan revealed dilated small bowel loops with oral contrast leaking into the peritoneum. Emergency laparotomy was performed and she was found to have a perforated cecum at the level of ileocecal valve leading to two stage surgery for end ileostomy with resection of the cecum and terminal ileum. The surgical specimen revealed chronic active inflammation, ulceration and serositis with fibrinopurulent exudate. GMS stain was positive for fungal organisms with ribbon-like morphology suggestive of Mucormycosis. AFB stain was negative for acid-fast bacilli. Patient was started on parenteral antifungal medications with gradual improvement in her clinical condition. Mucormycosis is an often catastrophic, fulminating fungal infection, classically described in poorly controlled diabetics and profoundly immunosuppressed patients. Previously, two cases have been reported in Crohn's disease where combination therapy with anti-TNF therapy led to sinus and gastric mucormycosis. This is the first case of intestinal mucormycosis in Crohn's disease patient on long-term prednisone use. Although the approximate survival rate in mucormycosis is approximately 50%, mortality can be as high as 100% in cases of disseminated disease. In patients with high clinical suspicion for mucormycosis, the importance of early diagnosis, correction of underlying risk factors and treatment cannot be overemphasized.Figure: GMS stain of cecum mucosa, magnified ×600, showing ribbon like morphology of Mucor.

Quantifying Drug-seeking Behavior: A Case Control Study

Background Drug-seeking behavior (DSB) is common in the Emergency Department (ED), yet the literature describing DSB in the ED consists predominantly of anecdotal evidence. Study Objectives To perform a case-control study examining the relative frequency of DSB in suspected drug-seeking patients as compared to all ED patients. Methods We performed a retrospective chart review of 152 drug-seeking patients and of age- and gender-matched controls, noting which of the following behaviors were exhibited during a 1-year period: reporting a non-narcotic allergy, requesting addictive medications by name, requesting a medication refill, reporting lost or stolen medication, three or more ED visits complaining of pain in different body parts, reporting 10 out of 10 pain, reporting > 10 out of 10 pain, three or more ED visits within 7 days, reporting being out of medication, requesting medications parenterally, and presenting with a chief complaint of headache, back pain, or dental pain. Results The odds ratios for each studied behavior being used by drug seeking patients as compared to controls were: non-narcotic allergy: 3.4, medication by name: 26.3, medication refill: 19.2, lost or stolen medication: 14.1, three or more pain related visits in different parts of the body: 29.3, 10 out of 10 pain: 13.9, three visits in 7 days: 30.8, out of medication: 26.9, headache: 10.9, back pain: 13.6, and dental pain: 6.3. Zero patients in the control group complained of greater than 10-out-of-10 pain or requested medication parenterally, resulting in a calculated odds ratio of infinity for these two behaviors. Conclusions Requesting parenteral medication and reporting greater than ten out of ten pain were most predictive of drug-seeking, while reporting a non-narcotic allergy was less predictive of drug-seeking than other behaviors.

Antiparasitic Therapy

Parasitic diseases affect more than 2 billion people globally and cause substantial morbidity and mortality, particularly among the world's poorest people. This overview focuses on the treatment of the major protozoan and helminth infections in humans. Recent developments in antiparasitic therapy include the expansion of artemisinin-based therapies for malaria, new drugs for soil-transmitted helminths and intestinal protozoa, expansion of the indications for antiparasitic drug treatment in patients with Chagas disease, and the use of combination therapy for leishmaniasis and human African trypanosomiasis.

Acute treatment of agitation in schizophrenia

Agitation in patients with schizophrenia is a serious condition seen frequently in emergency settings. Control of agitation, and in its extreme form violence, represents a significant challenge for healthcare providers. Historically, most interventions for agitation in the acute care setting have focused on medications and restraint, not on verbal de-escalation or other non-pharmacologic calming techniques. Recent expert consensus, however, recommends a non-coercive, collaborative approach to quell agitation if this can be done safely. Oral antipsychotics are preferred interventions in these collaborative interventions. The use of restraints and intramuscular medications should be a last resort; the authors recommend the use of atypical antipsychotic parenteral medications in such cases, as these tend to be efficacious yet with a more benign side-effect profile than traditional agents.

Effect of the probiotic biostim lbs in acute in toxication after industrial acci dents

A probiotic is a "live microbial food in gredient that, when in gested insufficient quantities, exerts health benefits on the consumer". The profound research of a range of Bulgarian scientists has allowed for the development in the last 15-20 years of original Bulgarian probiotic, milk-acid low-lactose products, united in the Biosim LBS (Lactoflor, Biomilk) series. This survey gives an overview of the effect of probiotic Biostim LBS in acute in toxications after industrial accidents. The mean energy values in kcal of the nutritional therapy applied intravenously and via oral route in 186 patients with intoxications with moderate severity are presented. The data show that Biostim LBS covers a mean energy value of 45.36% of the food applied orally in the group with moderate and 70.86% in the group of patients with severe intoxication. These results have been achieve dowing to the correct choice of therapy which have included mutually additive enteral and parenteral medications. In none of the patients adverse events have been observed regarding the parenteral medications and the enterally introduced Biostim LBS as well. They exerted beneficial effect on the metabolism, improved body energy levels and contributed to the absorption of energy and proteins. A special attention should be paid to the probiotic properties of the viable cells of L. bulgaricus, which favorably influence on the organism of the patients by improvement and regulation of the internal bacterial equilibrium. Scripta Scientifica Medica 2011;V.43(1):39-41

Transmission of hepatitis C virus to recipients of parenteral vitamin therapy in a primary care facility

Background and objectives The Australian prevalence of hepatitis C virus (HCV) is approximately 1%, with the majority of cases acquired through injecting drug use. However, occasionally HCV infection occurs in healthcare settings. Three new HCV infections were identified amongst patients attending a general practice in Sydney, Australia, specialising in parenteral vitamin therapy. Study design An investigation was conducted to identify the source of infection and mechanism of transmission. Molecular analysis was conducted by sequencing the HCV NS5A, Core and NS5B regions. Results Two sources were identified using molecular epidemiology – a genotype 3a case was the source for a case acquired in late 2004 and a genotype 1b case the source for one case acquired in late 2006 and another in early 2007. The common risk factor was parenteral vitamin C therapy. Conclusions Inadequate infection control was apparent and likely to have resulted in blood contamination of the healthcare workers, their equipment, the clinic environment and parenteral medications. Molecular and clinical epidemiology clearly identified parenteral transmission of HCV, highlighting the risks of blood contamination of parenteral equipment and use of multi-dose flasks on more than one patient.

Pharmaceutical Dosage Forms: Parenteral Medications Volume 1, 2nd Edition: Edited by Kenneth E. Avis, Herbert A. Lieberman and; Leon Lachman

Pharmaceutical Dosage Forms: Parenteral Medications Volume 1, 2nd Edition: Edited by Kenneth E. Avis, Herbert A. Lieberman and; Leon Lachman

Particulate contaminants of intravenous medications and infusions.

Particulate contamination in small volume parenteral medications has been studied and compared with that found in a selection of large volume infusions. Particle counts in 39 commonly used small volume medications and 7 large volume infusions were performed by an automated light blockage method (HIAC) or by optical microscopy. Based on these results and a random survey of drug therapy of intensive care patients, it is concluded that the contribution of intravenous medications to the total particle load received by such patients is likely to be many times greater than from infusion fluids. Until firm evidence regarding the harmful systemic effects of drug particles is available and the manufacturing regulations adjusted appropriately, final in-line filtration of infusions immediately proximal to the intravenous cannula should be considered when drugs are being given intravenously.

Headache in the Emergency Department

Emergency-medicine clinical researchers concentrate on optimizing diagnostic workups and treatment protocols, as well as improving throughput in an emergency department. This past year has yielded a wealth of clinical research focused on headache, which should streamline the diagnostic workup of nontraumatic headaches (particularly the search for subarachnoid hemorrhage) and several comparative efficacy trials, which help clinicians determine how best to treat acute migraine with parenteral medications. Herein, we review and contextualize the most important recent developments with regard to management of headache in the acute care setting.

Vancomycin in the Treatment of Pediatric Staphylococcal Infections

The authors recommend that pharmacists be consulted in the use of nephrotoxic parenteral medications in children to minimize any potential adverse reactions. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.