randomized placebo-controlled trial of clonidine impact on sedation of mechanically ventilated ICU patients

Clonidine has sedative and analgesic properties. Randomized studies examining these properties in mechanically ventilated ICU patients are scarce. This study was designed to assess the impact of clonidine on sedative agent use in mechanically ventilated patients. In a prospective, randomized, double blind, placebo-controlled study in a general ICU of a university medical center in Tehran, Iran, 40 patients, over 18 years on mechanical ventilation for 3 days or more randomized into 2 equal groups of clonidine and placebo. Clonidine arm received usual sedation and enteral clonidine 0.1 mg TID and escalated to 0.2 mg TID on the second day if hemodynamics remained stable. Ramsay Sedation Score was used to assess sedation. Opioids and midazolam were used in all patients. 10 patients in clonidine and 3 in placebo arms had history of drug abuse [P = 0.018]. The mean of sedatives used in the clonidine/placebo arms [mg/day] were; MED [Morphine Equivalent Dose] 91.4 +/- 97.9/112.1 +/- 98.8 P=0.39, midazolam 7.1 +/- 7.9/8.3 +/- 9.2 P=0.66 and propofol 535.8 +/- 866.7/139.1 +/- 359.9 P=0.125. After adjusting for addiction and propofol, clonidine reduced MED use by 79.6 mg/day [P=0.005] and midazolam by 5.41 mg/day [P = 0.05]. Opioids and midazolam need reduced by clonidine co-administration regardless of history of drug abuse. Acceptable side effect profile and the lower cost of clonidine could make it an attractive adjunct to sedative agents in ICU

Carbapenem restriction and its effect on bacterial resistance in an intensive care unit of a teaching hospital

Development of antibiotic resistance in Intensive Care Units [ICUs] is a worldwide problem. The purpose of this study was to evaluate the effect of an antibiotic stewardship program [ASP] by carbapenems restriction on gram-negative antimicrobial resistance in ICU. The study was designed in a 21 bedded general ICU of a teaching hospital with two wings [one and two] in Tehran, Iran. Carbapenem prescription in ICU1 was restricted to only the culture proven multi-drug-resistant bacteria with the absence of sensitivity to other antimicrobial agents. Carbapenem had to be prescribed by a trained ICU physician with close consultation with infectious disease specialist and the clinical pharmacist posted in ICU. Post-prescription reviews and de-escalations were carried out by the same team on regular basis. Restriction policy was commenced in January 2011 in ICU1. All documented infections and resistance patterns of isolated pathogens were recorded in both ICUs during two periods of 6 months before and 9 months after restriction policy implementation. During this study bacterial growth was detected in 51.5% of 1601 samples. Carbapenem administration was decreased from 6.86 to 2.75 DDD/100 patients day [60% decreases] pre-restriction and post-restriction respectively. Significant increase in sensitivity of pseudomonas to imipenem was observed in ICU1 comparing with pre-restriction period six months post restriction [p = 0.000]. Sensitivity of Klebsiella and Acinetobacter to imipenem did not change significantly during the study period. Our study demonstrated that restriction of carbapenems can increase sensitivity of P. aeroginosa to imipenem

Acute effects of hemodialysis on pulmonary function in patients with end-stage renal disease

Despite many beneficial effects, hemodialysis may cause pulmonary dysfunction. On the other hand, patients with end-stage renal disease are potentially prone to lung edema and respiratory dysfunction. This study was conducted to evaluate the alterations of pulmonary function indicators after hemodialysis, measured by spirometry. A total of 26 patients on hemodialysis for at least 3 months were studied. They were all older than 18 years old. None of the patients was a current or recent smoker, and none of them had a history of respiratory diseases, current or recent respiratory infections, musculoskeletal disorders, or tuberculosis. All of the patients underwent the spirometry test before and after a 4-hour hemodialysis session, and the forced expiratory volume in the first second [FEV1], forced vital capacity [FVC], vital capacity [VC], and FEV1/FVC ratio were measured. After hemodialysis, the FVC significantly increased [P = .02], while no significant improvement in the FEV1, VC, and FEV1/FVC ratio were observed. Gender was related to the changes in VC, with better results in women [P < .001]. There was no association between the changes in spirometry parameters and age, body mass index, cause of kidney failure, type of anion used for hemodialysis, and weight changes. According to our results, pulmonary function, especially the FVC, improves after a session of hemodialysis

Comparison between the preventive effects of ranitidine and omeprazole on upper gastrointestinal bleeding among ICU patients

Critically ill patients may develop visible gastric mucosal injury and stress ulcer soon after admission to an intensive care unit causing upper gastrointestinal bleeding as an important complication. Histamine-2 receptor antagonist [H2RA] prophylactic therapy has been documented to significantly decrease the incidence of upper GI bleeding in critically ill patients. This study was carried out in order to compare the effects of intravenous doses of ranitidine and enteral form of omeprazole suspension on preventing GI bleeding among ICU patients. This study was a double-blind randomized clinical trial conducted on patients admitted to the ICU at the Imam Hossein Hospital in Tehran, Iran. The patients were randomly divided into two groups of A and B. In group A, ranitidine was used as the prophylactic drug against GI bleeding with the dosage of 50 mg two times a day accompanied by placebo gavages through nasogastric tube. In group B, 20 mg of a suspension of omeprazole two times a day was gavaged in addition to 2[cc] of a parenteral placebo drug. Of 198 patients admitted to the ICU, 69 patients did not meet the inclusion criteria and a total of 129 patients enrolled in this study. During the study 14[20.58%] cases in the ranitidine group and 3[4.9%] in the omeprazole group developed significant GI bleeding. Incidence of GI bleeding showed a significant difference between the two groups using the chi-square test. Of the 68 patients receiving ranitidine, 44 [67.7%] died. This rate was 38 in those receiving omeprazole [62%]. Of the patients given ranitidine who faced overt GI bleeding, 12 [85.7%] died. This rate was 3 in the omeprazole group [100%].This study showed a statistically significant difference between omeprazole and ranitidine in preventing overt GI bleeding among ICU patients; but it failed to indicate any difference in prophylaxis of clinically important GI bleeding between the two drugs