Contamination of propofol infusions in the intensive care unit: incidence and clinical significance.

Epidemics of bacteraemia and wound infection have been associated with the infusion of bacterially contaminated propofol administered during anaesthesia. We conducted an observational study to determine the incidence and clinical significance of administration of potentially contaminated propofol to patients in an ICU setting. One hundred patients received a total of 302 infusions of propofol. Eighteen episodes of possible contamination of propofol syringes were identified, but in all cases contamination was by a low-grade virulence pathogen. There were no episodes of clinical infection or colonization which could be attributed to the administration of contaminated propofol. During the routine use of propofol to provide sedation in ICU patients the risk of nosocomial infection secondary to contamination of propofol is extremely low.

Severe falciparum malaria with hyperparasitaemia treated with intravenous artesunate.

We report a 57-year-old man with falciparum malaria contracted in Kenya who presented with a three-day history of symptoms. Despite prompt treatment with quinine and artesunate and rapid clearing of the parasitaemia, he developed multiple complications and died 28 days after presentation. This case illustrates the potential for malaria to be fatal despite appropriate treatment and is one of the first reports of the use of artesunate in a hospital in a developed country.

Reversal of midazolam sedation with flumazenil.

OBJECTIVE: To demonstrate the efficacy of flumazenil in reversing the sedative action of midazolam in ventilated intensive care patients. DESIGN: Prospective, double-blind randomized study. SETTING: ICU of a tertiary, university-affiliated teaching hospital. PATIENTS: Thirty ICU patients requiring artificial ventilation for greater than 12 hrs were studied. INTERVENTIONS: All patients received a midazolam infusion for sedation. Twenty-nine patients received supplementary narcotics. At the end of the sedation period, either flumazenil or placebo was administered to all the patients in a double-blind, randomized fashion, and the effects were observed. MEASUREMENTS AND MAIN RESULTS: Sedation levels were measured hourly during the infusion; at the end of the infusion; and at 5, 15, 30, 60, and 120 mins after cessation of the midazolam infusion. Midazolam concentrations in serum were measured at the time of cessation of the midazolam infusion and at 30, 60, and 120 mins later. Reversal of sedation was observed in 14 of 15 patients who received flumazenil, and resedation occurred in seven of these patients. Reversal was not seen in any of the patients who received placebo. Midazolam serum concentrations were similar in both groups. CONCLUSION: Flumazenil in a dose of 0.15 mg is a safe drug that reverses the sedative effect of midazolam.

Inorganic fluoride in prolonged isoflurane sedation.

An 18-year-old girl received isoflurane sedation for 48 h to facilitate mechanical ventilation. This resulted in a serum inorganic fluoride level of 37.3 mumol.l-1 when the isoflurane was stopped. As the serum fluoride level may continue to rise after isoflurane and as this level is approaching toxicity, the role of isoflurane sedation in the critically ill should be approached cautiously.

Ten years of snake bites at Fremantle Hospital.

Seventy-six patients (30% children) were admitted to Fremantle Hospital over 10 years with suspected snake bite. Twenty-nine patients were definitely bitten, with 26 bites being witnessed. Of the 13 patients definitely envenomated, 11 had a coagulopathy although seven were asymptomatic; four other patients may have been envenomated. The dugite (Pseudonaja affinis) was probably responsible for most envenomations. Eleven of the 13 envenomated patients received antivenom (six brown snake, four polyvalent and one tiger snake antivenom). The patient envenomated by the tiger snake (Notechis ater occidentalis), a 13-year-old girl, was initially incorrectly treated with brown snake antivenom at a country hospital, and did not receive appropriate antivenom until 50 hours after the bite. She developed profound paralysis, rhabdomyolysis and renal failure, and required prolonged ventilation during her 53-day hospital admission, but survived without disability. Snake bite wounds should not be washed, so that venom can be identified from the wound. Attempts to kill snakes are dangerous, often leading to bites on the fingers. First aid measures of a pressure bandage and immobilisation, used in 13 of the 29 cases (45%), should be more widely publicised.

Phenelzine poisoning.

A 46-year-old female with severe phenelzine poisoning was managed successfully by alpha blockade and fluid loading, with the aid of invasive haemodynamic monitoring. The pathophysiology was documented, showing elevated plasma and urinary catecholamines, cardiovascular abnormalities and a contracted blood volume. Most of these changes were reversed following treatment.