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Introduction: There is a dearth of information on older users (65+ years) of medical cannabis, who may face unique challenges due to altered metabolism with aging, concurrent medication use, and risk of adverse effects. This observational study aimed to describe a large cohort of older medical cannabis users in Canada. Method(s): From Oct 2014 to Oct 2020, a commercial medical cannabis provider based in Canada collected anonymized data for research purposes from patient volunteers. Data included demographic, social, and health details (at intake) and cannabis products, self-perceived changes in symptoms and change in medications (at follow-up, variable duration). Cannabis products were categorized as cannabidiol (CBD) only, tetrahydocannabinol (THC) only or mixed CBD/THC. Of the mixed, formulations could be in 1:1 ratios (CBD+/THC+), predominantly CBD (CBD+/THC-) or predominantly THC (CBD-/THC+). Result(s): In total, 9766 subjects in the older cohort (65+ years old) completed the entire questionnaire (mean age (SD) = 73.6 (6.8) y, 60% female). They represented 23.1% of the total dataset (N = 42,267, mean (SD) =51.5 (16.8) y). The proportion of adults in the older cohort tended to increase over time (pre-2018: 17.6%;2018: 26.7%;2019: 31.2%;2020: 22.7%, when the overall intake decreased from 8869 to 5644). Among the older cohort, 15.5% were previous cannabis users and 67.7% were referred for chronic pain (mainly arthritis, chronic pain, lower back pain). Concomitant analgesic use was common (over-the-counter analgesics: 44.5%;opioids: 28.3%;NSAIDs: 24.5%). 7.9% of the sample (compared to 19.9% in the whole sample) were referred for psychiatric disorders, though 21.4% indicated antidepressant use and 12.3% indicated benzodiazepine use. Another 7% were referred for neurological disorders. Follow-up data were captured in visits (11,992) from 4698 older patients, averaging 2.5 visits per patient. The type of medical cannabis used changed over time, with increasing use of cannabis oil compared to herbal cannabis. In 2020, of 2478 visits, 78.9% use was cannabis oil and 6.7% was herbal forms (pre-2018: 57.6% vs 36.2%). The composition of cannabis oil demonstrated a preference for cannabinoid oil (CBD+) over tetrahydrocannabinol (THC+) in 6043 visits: 45.2% were using CBD+ preparations, only 3.2% were using THC+ preparations, and for CBD/THC combinations, CBD predominated (CBD+/THC-: 30.5%;CBD+/THC+: 16.8%;CBD-/THC+: 4.3%). Adverse-effects (7062 visits) included dry mouth (15.8%), drowsiness (8.6%), dizziness (4%) and hallucinations (0.6%). Patients reported improved pain, sleep and mood over time, though 15-20% reported no improvement or worsening. Medication use was mostly unchanged, though 40% of opioid users reported requiring reduced dosages. Conclusion(s): These data were drawn from a large convenience sample. The data suggest an increasing proportion of older users of medical cannabis, though COVID-19 may have affected recent use. Female users comprised a higher proportion, and cannabis oil containing CBD was preferred. Systematic studies of effectiveness and safety in older users of cannabinoids are needed given its increasing use. Funding(s): No funding was received for this work.Copyright © 2021
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The prescription of benzodiazepines is governed by rules to ensure that the medication is taken in a healthy way. From the start of the Covid-19 pandemic, increased attention was paid to these rules given the respiratory risk of the disease and the drug interactions with its treatment protocols. With regard to what has been mentioned above, this update will try to give an answer to the adaptation of the prescription of benzodiazepines in Covid-19 patients. © 2022, John Libbey Eurotext. Tous droits réservés.;La prescription des benzodiazépines est régie par des règles assurant une prise saine de médicaments. Dès le début de la pandémie Covid-19 une attention plus particulière a été accordée à ces règles vu le risque respiratoire de la maladie et les interactions médicamenteuses avec ses protocoles thérapeutiques. Pour tout ce qui est cité, cette mise au point va essayer de donner une réponse à l'adaptation de la prescription des benzodiazépines chez les patients Covid-19. © 2022 John Libbey Eurotext. All rights reserved.
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Objectives: Analgosedation of patients with severe respiratory failure due to coronavirus disease 2019 (COVID-19) proved to be challenging. Patients supported with venovenous extracorporeal membrane oxygenation (VV ECMO) seemed to require analgosedative drugs in high doses. This study reviews analgosedation practices in patients with COVID-19 associated severe respiratory failure supported with VV ECMO. Method(s): This is a retrospective, single-center registry study including all patients with COVID-19 associated severe respiratory failure that were supported with VV ECMO at our center. All sedative and analgetic drugs administered intravenously or via inhalation to patients for at least two hours were recorded and analyzed. Result(s): Between March 2020 and January 2022, 88 patients with COVID-19 associated severe respiratory failure were supported with VV ECMO at our center. Propofol and sufentanil were used most frequently for analgosedation in this cohort. Both drugs were co-administered following treatment standards established prior to the emergence of COVID-19 at our center. Sedative and analgetic drugs were switched to alternative regimens after a median time of 3 and 12.5 days. Alternative regimens included Isofluran, alpha-2- agonists (clonidine or dextomidine) or esketamine. Alpha-2- agonists were initiated at a median time of 2 days after starting VV ECMO support. Benzodiazepines were used primarily as last resort treatment option for sedation at our center. During the four waves of the pandemic experienced at our center, we experienced an increased average number of drugs needed for analgosedation. Conclusion(s): Analgosedation in critically ill COVID-19 patients supported with ECMO is challenging. It remains unclear, whether the standard analgosedation regimen with sufentanil and propofol established at our center prior to the COVID-19 pandemic is optimal for this patient cohort. Further studies are needed to determine optimal and long term safe analgosedation regimens in critically ill patients supported by VV ECMO. Furthermore, changes experienced during the course of the pandemic need to be scrutinized in comparison to other cohorts. (Table Presented).
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Background: Many EP procedures are moving from the hospital to the ambulatory surgery center (ASC) outpatient setting. The COVID-19 pandemic and the CMS Hospitals Without Walls (HWW) program has been an impetus in accelerating this transition. Anesthesia provider perioperative management is critical in facilitating safe procedures with rapid, same-day discharge. Our EP-dedicated 2-OR ASC completed more than 3,000 procedures and more than 500 left-sided ablations utilizing general anesthesia with endotracheal intubation with same-day discharge. To our knowledge, this experience is unique within an ASC setting in both volume and complexity. Objective(s): We present our comprehensive anesthesia strategy and lessons learned to facilitate safe, efficient procedures and discharge in an EP ASC. Method(s): A nurse anesthesiologist with more than a decade of EP-dedicated experience developed and taught a perioperative anesthesia strategy to facilitate high volume, safe and quick discharge care. Fundamental to this is the avoidance of opioids and benzodiazepines whenever possible. Propofol or general anesthesia with sevoflurane and complete reversal with sugammadex allow for quick recovery. Mandatory video laryngoscope utilization minimizes airway trauma, while liberal antiemetic use eliminates most nausea. All femoral access is device closed. Positive inotropes are used liberally during anesthetic to avoid heart failure. The goal is to deliver all patients to PACU on room air with stable hemodynamics. Anesthesia providers manage the preop and recovery area. Result(s): More than 90% of all patients undergoing general anesthesia and heparinization for left-atrial ablation were discharged home in under 3 hours. Nearly all procedures not requiring femoral access were discharged within 30-60 minutes. High procedure volumes with efficiencies far exceeding our in-hospital experience were thus facilitated with improved patient safety. Since HWW began, five patients have required transfer to the hospital without any deaths. All others were discharged same day. Conclusion(s): We suggest that a dedicated anesthesia team with a tailored perioperative anesthesia plan facilitates performing nearly all EP-related surgical procedures in an ASC. This success is facilitated by appropriate patient selection, preoperative evaluation, intraoperative care prioritizing quick return to baseline, and end-to-end anesthesia perioperative management. We believe this type of anesthesia management is critical to the transition of EP procedures to ASCs.Copyright © 2023
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INTRODUCTION AND OBJECTIVE: Psychotropic medications have a significant impact on sexual health. Long-term usage is strongly associated with dyspareunia, decreased libido, hypogonadism and erectile dysfunction. We hypothesized that the prescription rates for psychotropic medications increased in adolescent patients during the COVID-19 pandemic because of the unprecedented stress levels on youth in isolation. Therefore, we evaluated the prescription rates of psychotropic medications as well as concurrent use of PDE5i in adolescent patients during the COVID-19 pandemic compared to the pre-pandemic era. METHOD(S): We utilized data generated from TriNetX Research Network to conduct a retrospective matched cohort study. Adolescent patients aged 10-19 presenting for outpatient evaluation were placed into two cohorts: 1) outpatient evaluation before and 2) during the COVID-19 pandemic. Patients with prior psychiatric diagnoses and those with prior use of psychotropic medications were excluded. The outcomes of interest were new prescriptions within 90 days of outpatient evaluation. Propensity score matching was performed using logistic regression to build cohorts of equal size. RESULT(S): A total of 1,612,283 adolescents pre-COVID-19 and 1,008,161 adolescents presenting during the COVID-19 pandemic for outpatient evaluations were identified. After propensity matching, a total of 1,005,408 adolescents were included in each cohort each withan average age of 14.7 +/- 2.84 and 52% female and 48% male. Prescribing of antipsychotics and benzodiazepines were more frequent during the pandemic for adolescents (RR: 1.58, 95% CI 1.01-2.2). However, they were less likely to receive antidepressants (Risk Ratio (RR): 0.6, 95% Confidence Interval (CI) 0.57-0.63), anxiolytics (RR: 0.78, 95% CI 0.75-0.81), stimulants (RR: 0.26, 95% CI 0.25-0.27), as well as mood stabilizers (RR: 0.44, 95% CI 0.39-0.49). Erectile dysfunction requiring oral PDE5i in this cohort was more frequent during the pandemic for adolescents (RR: 1.53, 95% CI 1.05-2.01). CONCLUSION(S): The rates of antipsychotic and benzodiazepine prescriptions increased during the COVID-19 global pandemic compared to preceding years. This coincided with a statistically significant increase in the prescription of PDE5i for erectile dysfunction. Adolescents may face an increased risk of sexual dysfunction as both their illness and the medications they are prescribed both have a positive association with sexual dysfunction. Clinicians must be cognizant of the fact that adolescents may face an increased risk of medication related sexual dysfunction.
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This case study draws attention on mental health sequelae that emerged in the context of the COVID-19 outbreak after recovery from hospitalization, even in subjects without personal psychiatric history. The case involves a 65-year-old male shift nurse who took SARS-COV-2 infection through a co-worker and that had been hospitalized for interstitial pneumonia from April 6 to April 17. After recovery, he developed psychiatric symptoms overlapping between different dimensions of psychiatric disorders and started to be followed by the Occupational Health Department of a Major University Hospital in central Italy. He reported a score of 28 at the Peritraumatic Distress Inventory and of 39 at the Self-Rating Anxiety State. He was treated with a combination therapy of SSRI and NaSSA antidepressants with clinical remission. In this case study, authors discuss the possible overlapping role of post-traumatic stress and anxiety symptoms in patients discharged after COVID-19 hospitalization that may deserve appropriate classification, treatment and follow up with the future goal to refine clinical management of post and long COVID syndromes of subjects who present low abnormalities in other specialty investigations.Copyright © 2022 EDIZIONI MINERVA MEDICA.
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Background/Purpose: Pediatric Acute Lymphoblastic Leukemia (ALL) affects ~4000 young Americans each year. Steroids are essential to curative ALL treatment yet have significant neuropsychiatric side effects that decrease quality of life for patients and families. However, incidence and predisposing risk factors are not well understood. This review aims to describe the current literature on neuropsychiatric side effects of steroids in Pediatric ALL. Method(s): A precise search in PubMed and Embase was cultivated using controlled vocabulary terms (MeSH, Emtree) and keywords for the following concepts: pediatrics, steroids, side effects, cancer, and neurobehavioral manifestations. Keywords and controlled vocabulary for each subject were arranged logically and combined with other concepts by Boolean Logic, using the Boolean operator AND, resulting in 642 precise results exploring neurobehavioral side effects of steroids in children with cancer. Results (2010 to date of search) were imported into Covidence systematic review software, and reviewed by SB and AM. Result(s): Twenty-three articles met inclusion criteria. There is marked variability in research methodology and no standard measurement of neuropsychiatric symptoms. Commonly reported symptoms include mood swings, irritability, depression, anxiety, aggression, insomnia, mania, and psychosis with prevalence between 5% and 75%. Heterogeneous research methodology and descriptions of psychiatric symptoms make it difficult to determine risk factors, though dexamethasone, family psychiatric history, and younger age are consistently associated with greater risk of behavioral dysregulation. Genetic predisposition (Bcl1 polymorphism, SNPs in GR gene) may increase susceptibility to developing depression during treatment. Data suggest variable efficacy of antipsychotics, benzodiazepines, hydrocortisone, and potassium-chloride. Conclusions and Implications: Existing data about neuropsychiatric side effects of steroids in pediatric ALL is extremely heterogeneous, creating challenges for standardized assessment and treatment. The burden of these symptoms necessitates further research to identify and treat vulnerable patients. Standard measurement of these symptoms could be a first step in eventually alleviating this source of distress.
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The article discusses the issues of terminology, epidemiology, etiopathogenesis, clinical manifestations, approaches to the diagnosis and treatment of post-covid syndrome (PCS). It has been shown that the incidence of PCS in people who had COVID-19 is 10-35%;there are no generally accepted approaches to defining the term PCS. Clinical manifestations of PCS include more than 50 symptoms that occur in both children and adults, regardless of their place of residence. The damage caused by metabolites of the systemic inflammatory response of the central nervous system with the formation of a syndrome of autonomic dysfunction, cognitive impairment, and affective disorders is of critical importance in the genesis of PCS. Antipsychotics, antidepressants, and benzodiazepine drugs are used in the correction of PCS. However, they have limitations, in particular - when used in children with comorbid disorders. The use of aminoacetic acid (glycine), which has a wide range of safety, anxiolytic, anti-inflammatory, and nootropic effects in the correction of PCS, can become an effective therapeutic strategy.Copyright © Team of Authors, 2022.
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This article discusses the treatment of panic disorder in terms of cognitive behavioral psychotherapy. Panic disorder is one of the most common anxiety disorders. The etiology of panic disorder assumes the coexistence of genetic and environmental factors. Panic attacks often accompany other mental and somatic diseases. The constant feeling of intense anxiety with a number of somatic symptoms affects the deterioration of everyday functioning, significantly reducing one's quality of life. The global situation caused by SARS-CoV-2 may correlate with the increase in the incidence of panic disorder. The introduction of appropriate therapeutic interventions at the earliest possible stage of the disease gives patients a chance for long-term remission. So far, it has been proven that the best results of pharmacological treatment are achieved thanks to the antidepressant and benzodiazepine drug groups. One of the non-pharmacological interventions with the highest clinical effectiveness is cognitive-behavioral psychotherapy. Compared to other trends, cognitive- behavioral therapy is characterized by the most reliable research proving its high effectiveness. Psychotherapy of panic disorders in the cognitive-behavioral approach includes a complete conceptualization of the patient's problem, taking into account individual theoretical models. Treatment of panic attacks is based on a protocol which takes into account both cognitive and behavioral interventions, e.g. psychoeducation, cognitive restructuring, breathing training, relaxation exercises and both interoceptive and in vivo exposures. Research results indicate that this therapy is an alternative form of treatment for panic disorders. Sources indicate that the effectiveness of interventions based on cognitive-behavioral therapy is comparable to that of pharmacotherapy.Copyright © 2022 Termedia Publishing House Ltd.. All rights reserved.
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Introduction: The first six months of the COVID-19 pandemic saw a nearly 50% increase in pediatric mental health emergencies. Specific factors contributing to this rise remain poorly characterized. One frequently cited contributor is pandemic-related interruptions of in-person schooling. Early studies indicate that students have experienced significantly greater psychological distress during such disruptions. We set out to investigate what correlation, if any, exists between school modality (ranging from exclusively virtual to exclusively in-person) and pediatric mental health status. Method(s): This is a retrospective, descriptive study combining patient chart review and parental telephone survey, exploring the prevalence and severity of mental illness among inpatients at a single urban, academic, midwestern tertiary care center. The study population included all patients ages 6-18 admitted to the study site during the 2015-19 and 2020- 21 school years who received Psychiatry and/or Psychology consults and/or were admitted to the inpatient psychiatry unit. Parents/guardians of participants from 2020-21 were surveyed regarding their child' educational experiences. We describe and compare participants between school years prior to and during the pandemic using descriptive demographic data and clinical data highlighting monthly admission rates and proxies for illness severity. We then assess for any correlation between these measures and recent virtual schooling. Result(s): Total mental health-related admissions rose from an average of 1070 during pre-pandemic school years to 1111 in 2020-21. Patients admitted in 2020-21 were more likely to be female, non-white, and from ZIP codes with higher median income. Primary diagnosis was more likely to be a mood or eating disorder. Patients were less likely to present primarily for suicidal ideation or self-harm. Proxies of illness severity, including utilization of PRN antipsychotics/benzodiazepines and readmission rates, rose in 2020-21. 255 of 800 (31.9%) families responded to the telephone survey. Respondents were more likely to have a child who was female and slightly younger compared to non-respondents. 98% of respondents reported some virtual schooling for their child, with 77% reporting virtual schooling for the majority of the three months prior to their child' first hospital admission. 61% indicated their child was exclusively in virtual school. No significant relationships were observed between virtual schooling and any outcome measures relating to mental health. Conclusion(s): Pediatric mental health emergencies and hospitalizations have grown and evolved since the start of the COVID-19 pandemic. This study characterizes some of the changes in patient demographics and experience with virtual schooling prior to and following the pandemic. Our results do not support any correlation between virtual schooling and mental illness requiring emergent care or hospitalization. However, this study has many significant limitations. Respondents were not representative of all admitted patients, and survey data were gathered for only one-third of families whose children were admitted at one site. Very few respondents remained in school in person throughout the pandemic, complicating efforts to make meaningful comparisons. Future work should attempt to capture a broader subject pool and obtain prospective data regarding the effects of school modality on mental health.
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Recent years have been associated with the development of various sensor-based technologies in response to the undeniable need for the rapid and precise analysis of an immense variety of pharmaceuticals. In this regard, special attention has been paid to the design and fabrication of sensing platforms based on electrochemical detection methods as they can offer many advantages, such as portability, ease of use, relatively cheap instruments, and fast response times. Carbon paste electrodes (CPEs) are among the most promising conductive electrodes due to their beneficial properties, including ease of electrode modification, facile surface renewability, low background currents, and the ability to modify with different analytes. However, their widespread use is affected by the lack of sufficient selectivity of CPEs. Molecularly imprinted polymers (MIPs) composed of tailor-made cavities for specific target molecules are appealing complementary additives that can overcome this limitation. Accordingly, adding MIP to the carbon paste matrix can contribute to the required selectivity of sensing platforms. This review aims to present a categorized report on the recent research and the outcomes in the combinatory fields of MIPs and CPEs for determining pharmaceuticals in complex and simple matrices. CPEs modified with MIPs of various pharmaceutical compounds, including analgesic drugs, antibiotics, antivirals, cardiovascular drugs, as well as therapeutic agents affecting the central nervous system (CNS), will be addressed in detail.Copyright © 2023 Elsevier B.V.
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Status epilepticus is the second most common neurological emergency with 15â25% mortality rate. The principle of "time is brain" is also true for the treatment of status epilepticus: the earlier we start an adequate treatment, the more likely we are to stop progression. With treatment protocols based on high-level evidence, the progression of status epilepticus can be prevented in 7590% of cases: we can avoid the induced coma or death. At the beginning of status epilepticus, parenteral benzodiazepine should be given immediately: intramuscular midazolam (0.2 mg/kg, max. 10 mg). In the case of easy veinous access, benzodiazepines can also be given intravenously. If the first benzodiazepine bolus does not stop the status epilepticus, we speak about established (benzodiazepine refractory) status epilepticus. In this case, a fast-acting non-benzodiazepine antiepileptic drug should be given: intravenous valproate (40 mg/kg, max. 3000 mg, within 10 minutes) or levetiracetam (60 mg/kg, max. 4500 mg, within 10 minutes). Refractory status epilepticus that persists for more than 1 hour and does not respond to either benzodiazepines or antiepileptics should be treated with general anesthesia (full narcosis). Induced coma can be achieved with fast-acting anesthetics, a combination of propofol with midazolam is the most frequently used one. Orv Hetil. 2020; 161(42): 17791786.
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Status Epilepticus , HumansABSTRACT
BACKGROUND: Catatonia is a syndrome that may present with stupor, immobility, and postural retention, and appears in various primary disorders including schizophrenia, depressive disorders, and neurodevelopmental disorders. CASE PRESENTATION: In this report, we describe a 34-year-old female patient with schizophrenia, who had previously been treated with antipsychotic agents to improve psychotic symptoms with delusional symptoms and catatonia. However, she relapsed with catatonic symptoms around 1 year after she voluntarily discontinued the prescribed antipsychotic medications by herself. Her catatonia was successfully improved using the transdermal blonanserin patch, a drug formulation globally first approved in Japan in 2019. DISCUSSION: Although benzodiazepines or electroconvulsive therapy have been recommended as the first-line treatment of catatonic manifestation observed in psychiatric patients, this patient responded well to antipsychotic blonanserin. From the differential drug responses, catatonia may be the complex of heterogeneous conditions with different pathophysiologies.
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Antipsychotic Agents , Catatonia , Schizophrenia , Humans , Female , Adult , Schizophrenia/drug therapy , Antipsychotic Agents/therapeutic use , Catatonia/diagnosis , Catatonia/drug therapy , Transdermal PatchABSTRACT
Background: Psychotropic drug consumption has increased during the COVID-19 pandemic. We describe here the prevalence and identifying factors associated with Benzodiazepine (BZD) and Z-hypnotics use among a sample of Spanish adults suffering from long-COVID-19 syndrome, from a gender perspective. Materials and methods: Data were anonymously collected between 15th December 2021 and 15th March 2022. The collection form consisted of several questions gathering sociodemographic information, post-COVID symptom, health profile, and pharmacological drug intake. Using logistic multivariate regression models, we estimated the independent effect of each of these variables on self-medicated consumption. Three models were generated (female, male, and both gender). Results: Prevalence of BZD and Z-hypnotics use was 44.9% (46.5% for women; 37.8% for men). Zolpidem was the most consumed drug among male (20.7%), and lorazepam in female (31.1%). Patterns of drug consumption among female were related with number of post-COVID symptoms and smoking habit (AOR 2.76, 95%CI 1.16-6.52). Males under 40 years of age are more likely to consume BZD and Z-hypnotics (AOR 5.52, 95%CI 1.08-28.27). Conclusion: The prevalence of consumption of BZD and Z-hypnotics in those subjects with long-COVID-19 in our study reaches values of 44.9%. Women with long-COVID-19 declare a higher prevalence of consumption than men. Predictors of BZD and Z-hypnotic in men were, age and number of medication use. Smoking habit and the number of post-COVID symptoms were predictive variables in women.
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Background: More and more, young children are victims of the ongoing epidemic of opioid use disorder. Xylazine, an alpha-2 adrenergic agonist with notorious use as a veterinary tranquilizer, is an increasingly encountered component of the illicit opioid supply in the US, but has been rarely documented in biological samples obtained from children. We report a 19-day-old infant with classic manifestations of central nervous system and respiratory depression associated with fentanyl and xylazine poisoning. Case report: A 19-day-old boy was taken to the emergency department (ED) by his parents for episodes of straining, breathholding, and his eyes rolling backwards. The formula-fed boy was born of an uncomplicated full-term spontaneous vaginal delivery and had previously been thriving. During ED triage assessment he had a period of apnea, then bradypnea, with pulse-oximetric oxygen saturation drop to 55%. He was supported with stimulation and supplemental oxygen via nonrebreather mask but remained lethargic, with temperature 96F, heart rate 166/min, and brisk capillary refill. Point of care blood dextrose testing was 88mg/dL. Analysis of respiratory secretions for common viruses by polymerase chain reaction was negative for respiratory syncytial virus, influenza, or SARS-CoV-2. Computed tomography imaging of the brain was unremarkable. A urine drug immunoassay (Vitros 4600 Chemistry , Ortho- Clinical Diagnostics) resulted positive for fentanyl (cutoff 1 ng/ mL), but negative for amphetamine, barbiturate, benzodiazepine, cannabinoids, cocaine, heroin, morphine, buprenorphine, methadone, or oxycodone. Liquid chromatography tandem mass spectroscopy analysis of the urine confirmed the presence of fentanyl (25 ng/mL) and norfentanyl (245 ng/mL). Gas chromatography with mass spectrometry also detected the presence of xylazine (qualitative result based on spectra matching). Over the ensuing hours the boy recovered fully and the family was connected with child protection services;an exposure route was not identified. Discussion(s): This 19-day-old infant suffered fentanyl/xylazine poisoning. The infant's age and urine fentanyl concentrations exclude pre-natal exposure as an explanation for the drug test findings, and the baby was bottle-fed excluding drug transmission through breast milk. Xylazine has been known to be in this hospital's regional heroin supply since the early 2000s, and in 2019 xylazine was implicated in more than 31% of opioid-associated deaths at the city's medical examiner's office. In 2022, many fentanyl samples tested by regional law enforcement find more xylazine than fentanyl. Until recently, xylazine was an uncommon finding in our testing of pediatric opioid poisoning victims. Similar to fentanyl, xylazine may cause pupillary miosis and CNS depression;unfortunately it may be resistant to reversal with naloxone. Conclusion(s): This case is remarkable for the young age of this infant ill from post-natal fentanyl poisoning and for the detection of xylazine in his urine. Healthcare providers may not immediately consider opioid poisoning in the differential diagnosis of infants with altered mental status, and proper toxicological testing is important for appropriate child protection support. Detection of xylazine is a marker for a non-medical, or "street," source of fentanyl.
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SESSION TITLE: What's New in Critical Care? SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Alcohol withdrawal syndrome (AWS) is a common etiology of intensive care unit (ICU) admission(Vigouroux et al 2021). Emergency Department (ED) related alcohol visits have increased in incidence dramatically since the beginning of the SARS-CoV2 pandemic. A median ICU length of stay (LOS) of 8 days for severe AWS has been previously reported. The increase in substance abuse observed during the pandemic may prolong future patients’ LOS. Pandemic staffing and bed shortages have made it even more evident the need to research efficient and safe treatment options of common hospital admission diagnosis such as AWS. Current national guidelines recommend benzodiazepines as first-line therapy for inpatient management of AWS (American Society of Addiction Medicine Clinical Practice Guidelines). However, historically phenobarbital (PB) and other barbiturates have been utilized with varying success. Recent evidence has demonstrated phenobarbital loading followed by symptom-triggered benzodiazepines may reduce LOS and ICU admission (Rosenson et al 2012). We retrospectively evaluated ED and ICU data to further guide our future research on PB in AWS, specifically;LOS, location of admission, and high risk side effects frequently associated with PB such as intubation. METHODS: Patients admitted for AWS and who received PB from 8/1/2021 to 02/01/2022 were identified. Subsequently, these subjects were then matched to themselves for historical AWS admissions without receipt of PB. Exclusion criteria included: admission with concomitant diagnosis with expected admission LOS longer than AWS treatment course;no separate admission for AWS. Pertinent patient demographics were collected including cumulative dosing of benzodiazepines, disposition from the ED, hospital LOS, ICU LOS, relative hypotension, and intubation. Data was analyzed using descriptive statistics and one-sided Student T-test. RESULTS: Total of 16 patients received PB during the six month identification period. Six were excluded due to lack of previous admission for AWS. Three were excluded for previous admissions with concomitant disease states requiring prolonged admissions. These included endoscopy, long-bone fracture, and subdural hematoma. Seven patients (14 unique admissions) met inclusion criteria. Patients were all male with a mean age of 58. Compared to non-PB admissions a trend in mean reduction of hospital LOS was 39.3 hours shorter in the PB cohort (p-value=0.068). Mean benzodiazepine reduction (lorazepam equivalents) was 26.3mg less in the PB cohort (p-value = 0.064). No intubations or hypotensive events were observed in either cohort. CONCLUSIONS: When PB was utilized there was reduction in total hospital LOS with no increase in intubations. Preliminary patient matched data of PB in AWS appears efficacious and safe. CLINICAL IMPLICATIONS: PB may decrease overall hospital LOS in AWS. DISCLOSURES: No relevant relationships by Yara Albair No relevant relationships by Nicholas Barreras No relevant relationships by Jessica Kim No relevant relationships by Marc McDowell No relevant relationships by Joshua Posner No relevant relationships by Mariana Silva