Use of stun guns for venomous bites and stings: a review.

During the past 2 decades, articles suggesting that stun guns be utilized to treat venomous bites and stings have appeared in both the lay and medical press. Although never widely considered to be standard therapy for venomous bites and stings, stun guns are still considered to be a treatment option by some medical practitioners and outdoor enthusiasts. A Medline search was performed using these terms: venomous bites, venomous stings, snake bites, spider bites, electrical, stun gun, high voltage electricity, low amperage electricity, direct current, and shock therapy. Articles selected included laboratory-based isolated venom studies, animal studies, and case reports involving humans in which a stun gun or some other source of high voltage, low amperage direct current electric shocks were used to treat actual or simulated venomous bites or stings. We concluded that the use of stun guns or other sources of high voltage, low amperage direct current electric shocks to treat venomous bites and stings is not supported by the literature.

Severe thrombocytopenia associated with alatrofloxacin.

OBJECTIVE: To report the development of severe thrombocytopenia during alatrofloxacin therapy. CASE SUMMARY: A 54-year-old Native American woman was admitted for pneumonia after completing a 10-day course of loracarbef 200 mg po bid. On admission, the woman was hypoxic (PO2 56 mm Hg) and had a platelet count of 408 x 10(3)/mm3. Alatrofloxacin 300 mg iv piggyback qd was initiated in the emergency department. The patient's condition gradually improved during the next three days. While preparing for discharge on hospital day 4, the patient developed epistaxis that lasted approximately three hours. Laboratory testing revealed a platelet count of 7 x 10(3)/mm3; stable red blood cell count, hemoglobin, and hematocrit values; and a normal white blood cell count. Alatrofloxacin therapy was discontinued and azithromycin was initiated on hospital day 4. Methylprednisolone 125 mg iv piggyback every 12 hours was initiated on hospital day 5. The platelet count fell to 2 x 10(3)/mm3 on hospital day 5 and then began to rise, reaching 60 x 10(3)/mm3 when the patient was discharged on hospital day 8. DISCUSSION: Numerous infectious, disease-related, environmental, and pharmacologic factors may cause thrombocytopenia. Drug-induced thrombocytopenia usually develops during the first two weeks of therapy and resolves within one week of drug discontinuation. Thrombocytopenia occurred in <1% of more than 7000 patients receiving alatrofloxacin or trovafloxacin during clinical trials. CONCLUSIONS: The time course of this patient's development of and recovery from thrombocytopenia suggests that it was induced by alatrofloxacin. Clinicians should monitor patients receiving alatrofloxacin or trovafloxacin for signs and symptoms of bleeding and thrombocytopenia.

Rapid infusion of amphotericin B in dextrose.

OBJECTIVE: To review the data examining the use of rapid infusion of amphotericin B in dextrose infusions. DATA SOURCES: A MEDLINE search of the English-language literature and review of pertinent references' bibliographies was used to identify articles evaluating the effect of amphotericin B infusion rates on the incidence of adverse reactions. STUDY SELECTION AND DATA EXTRACTION: Controlled and uncontrolled studies involving humans are reviewed; emphasis is placed on recent comparative trials. Pertinent information, as judged by the authors, was selected for discussion. DATA SYNTHESIS: Amphotericin B, a polyene antifungal agent with significant toxicity, remains the agent of choice for many serious fungal infections. The potential benefits of rapid administration of amphotericin B in reducing the incidence and/or severity of adverse reactions were noted soon after its introduction. Recent studies have examined the tolerability of rapid (0.75-1 h) amphotericin B infusions. Results of studies assessing the tolerability of rapid amphotericin B infusions suggest that tolerance to infusion-related reactions develops during therapy. Comparative trials have obtained variable results. The comparative trials supporting rapid amphotericin B infusion have generally used crossover designs, enrolled small numbers of patients, and excluded patients with significant renal or cardiovascular dysfunction. CONCLUSIONS: Rapid amphotericin B infusions should be avoided during initiation of therapy when infusion-related reactions tend to be most problematic, and in patients with cardiovascular disease, renal dysfunction, and potassium disorders because of the potential risk for cardiac arrhythmias. The literature currently available is conflicting and insufficient to support the routine use of rapid amphotericin B infusion.

Relationship between the administration of selected medications and falls in hospitalized elderly patients.

OBJECTIVE: To examine the relationship between administration of selected medications and falls experienced by hospitalized elderly patients. Benzodiazepines and other medications previously associated with falls in elderly patients residing in the community and nursing homes were the primary focus. DESIGN: Retrospective case control. SETTING: Private, not-for-profit, 575-bed acute care hospital. PARTICIPANTS: A total of 100 patients who had fallen and 100 control patients, aged at least 70 years, admitted during the same 17-month time period. MAIN OUTCOME MEASURES: We examined the relationship between falls and patient demographics, underlying disease states, number of concurrent disease states, and length of hospitalization. Possible associations between the administration of narcotics, benzodiazepines, antidepressants, antipsychotics, other sedating agents, antihypertensives, diuretics, nitrates, and digoxin 48 hours prior to the fall or reference day were explored. The relationships between benzodiazepine half-life, dosage, administration frequency, cumulative dose, and falls were also examined. RESULTS: Demographically the groups were similar except that patients who had fallen were hospitalized significantly longer (mean 18.8 vs 12.2 d; p < 0.00001) than control patients. Benzodiazepines were received by more (40% vs 20%, odds ratio = 2.67) patients who had fallen than control patients. The use of long (> 24 h) half-life benzodiazepines was similar in patients who had fallen (48%) and control patients (45%). Long half-life benzodiazepines were commonly administered (65%) to patients who had fallen in doses greater than that recommended for the elderly. Benzodiazepine use, expressed as milligrams of diazepam equivalents received during the 48-hour study, was higher in patients who had fallen than in control patients (15.00 +/- 17.80 vs 9.73 +/- 6.58 mg), but this was not statistically significant (p = 0.1030). Congestive heart failure (37% vs 24%), digoxin therapy (35% vs 22%), or administration of 3 or more psychoactive agents (17% vs 4%) were all more common in patients who had fallen than in control patients. CONCLUSIONS: Falls experienced by the elderly patients in our acute care institution were associated with the presence of congestive heart failure along with digoxin therapy, benzodiazepine use, or the use of at least 3 psychoactive agents.

Improved total parenteral nutrition therapy management by a nutritional support team.

This study was performed to identify and document the benefits associated with a multidisciplinary consult-based nutritional support team. The adequacy of nutritional support and incidence of metabolic complications were prospectively studied in 28 adult patients receiving total parenteral nutrition in a large private tertiary care institution during a 2-week period. Estimated daily caloric and protein requirements were met significantly more often in patients followed by our NST than in control group patients. Chloride and bilirubin abnormalities occurred significantly less often in the NST group than in the control group. The incidence of blood urea nitrogen, creatinine, and glucose abnormalities were also decreased in the NST patients, but these differences were not statistically significant. Patients followed by the NST were more likely to receive adequate nutrition and experience fewer metabolic abnormalities than when TPN therapy was guided solely by a physician.

Nutritional support teams: a review of comparative trials.

OBJECTIVE: To evaluate the literature describing the influence of nutritional support teams (NSTs) on the provision of nutritional therapy. DATA SOURCES: A MEDLINE and International Pharmaceutical Abstracts search (key terms: nutritional support, nutritional support service/team, hyperalimentation service/team, metabolic support service/team, service/team) covering 1970-1993 were used to identify pertinent literature. STUDY SELECTION: The results of comparative trials involving NSTs are presented. DATA EXTRACTION: Data from comparative trials examining the influence of NSTs on the provision of enteral nutrition (EN) and total parenteral nutrition are discussed. DATA SYNTHESIS: NSTs dramatically reduced the incidence of catheter-related complications, especially sepsis, by developing central venous catheter insertion and care guidelines. Early studies found that NSTs reduced the incidence of electrolyte and metabolic abnormalities by more stringent laboratory and clinical monitoring, but this was not found consistently in later studies. The ability of consultative NSTs to reduce the incidence of metabolic and electrolyte abnormalities is less clear. NSTs also were more likely to evaluate, document, and subsequently meet a patient's nutritional requirements. Studies examining the financial impact of NSTs frequently reported cost savings, but often failed to include personnel costs in their analysis. The provision of EN by an NST reduced the frequency of complications and increased the adequacy of nutritional supplementation. CONCLUSIONS: Early nutritional support teams produced significant benefits largely through the development of protocols and standardization. Current NSTs should increase the dissemination of information supporting their continued benefits. To remain viable, NSTs need to expand their roles, document improved patient outcomes, and show cost-effectiveness.

Granulocyte-colony stimulating factor for sulfasalazine-induced agranulocytosis.

OBJECTIVE: To report a case of sulfasalazine-induced agranulocytosis that was successfully treated with granulocyte-colony stimulating factor (G-CSF). CASE SUMMARY: An 82-year-old woman developed agranulocytosis within two months of initiating sulfasalazine therapy. She was hospitalized, empiric antibiotic and antifungal agents were prescribed, and sulfasalazine therapy was stopped. The patient received G-CSF 600 micrograms/d subcutaneously for six consecutive days, starting on hospital day 5. Agranulocytosis resolved on day 5 and leukopenia on day 6 of G-CSF therapy. No adverse reactions were attributed to administration of this agent and the patient was discharged on hospital day 13. DISCUSSION: Numerous agents, including sulfasalazine, have been associated with agranulocytosis. Agranulocytic patients frequently experience life-threatening bacterial and fungal infections. Administration of colony stimulating factors may reduce the duration of agranulocytosis and incidence of life-threatening infections. CONCLUSIONS: G-CSF administration appears to have decreased the duration of this elderly patient's agranulocytosis and hospitalization.

Adverse reactions to human serum albumin.

OBJECTIVE: To describe the adverse effects associated with human serum albumin (HSA) administration. DATA SOURCES: A MEDLINE search and bibliography scanning were used to identify pertinent review articles, clinical studies, and case reports. STUDY SELECTION: Emphasis was placed on reporting the results of human studies with the primary objective of investigating adverse effects attributable to HSA administration. Clinical trials that reported the occurrence of adverse effects possibly associated with HSA were also reviewed. Animal data were included where pertinent. DATA EXTRACTION: Although isolated case reports were reviewed, data were primarily extracted from human studies involving large series of patients or studies that were randomized and prospective in nature. DATA SYNTHESIS: Alterations in coagulation, renal, cardiovascular, and pulmonary functions were identified as potential adverse effects following the administration of HSA. Occurrences of hypersensitivity reactions, trace metal loading, and serum amino acid alterations associated with these infusions were also noted and are described here. Pulmonary and cardiovascular systems appear to be particularly prone to complications from excessive HSA administration. Adverse effects such as HSA-induced hypersensitivity reactions may be severe, but occur infrequently. CONCLUSIONS: Controlled studies involving large numbers of patients are not currently available for an accurate assessment of the incidence of adverse effects attributable to HSA administration. Many of the reported reactions appear to be extensions of albumin's pharmacologic activities and would be expected to worsen following large doses of HSA.

Mesalamine and olsalazine: 5-aminosalicylic acid agents for the treatment of inflammatory bowel disease.

The history, pharmacology, pharmacokinetics, clinical uses and efficacy, adverse effects, drug interactions, and dosage and administration of rectal mesalamine and oral olsalazine in the treatment of inflammatory bowel disease (IBD) are reviewed. The high incidence of toxicity associated with sulfasalazine led to the development of the nonsulfonamide 5-aminosalicylic acid products mesalamine and olsalazine. The exact mechanism of action of these agents in the treatment of IBD is unknown. In clinical trials, mesalamine was shown to be as effective as or more effective than sulfasalazine or corticosteroids in treating active ulcerative colitis, proctitis, and proctosigmoiditis. Mesalamine is effective in the maintenance of remission in patients with ulcerative colitis. Several studies have demonstrated the effectiveness of olsalazine in the treatment of active mild to moderate ulcerative colitis. Olsalazine is also effective in the maintenance of remission of ulcerative colitis. The most common adverse effect associated with mesalamine enemas is perianal irritation or trauma secondary to insertion. The most common adverse effects associated with olsalazine are dose-dependent watery diarrhea and gastrointestinal upset. The recommended dosage of the mesalamine enema for the treatment of active mild to moderate ulcerative colitis is one 4-g (60-mL) retention enema daily for three to six weeks. The dosage of mesalamine suppositories for the treatment of active ulcerative proctitis is one 500-mg suppository inserted rectally twice daily for three to six weeks. The dosage of olsalazine is 1 g daily in divided doses for the maintenance of remission of ulcerative colitis. Both rectal mesalamine and oral olsalazine provide clinicians with an effective therapeutic option for the treatment of ulcerative colitis, proctosigmoiditis, and proctitis in patients unresponsive to or intolerant of the effects of sulfasalazine or corticosteroids.

Albumin audit results and guidelines for use. University Medical Center, Tucson, Arizona.

OBJECTIVE: To identify patients receiving albumin, develop guidelines for albumin use, and examine distribution and billing procedures. DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: All patients received albumin in a four-week period. Patients were identified concurrently using intensive care unit surveys and the pharmacy computer system, and retrospectively using billing statements. Data were analyzed from 73 of 79 patients (92.4 percent); 6 (7.6 percent) had no record of albumin being ordered or administered. Pediatric patient data were used only in the financial calculations. DATA COLLECTION: Demographics and albumin dosages were recorded for all patients. Prescribing service and indications for use were recorded in adults. Albumin administered was compared with the amount billed to each patient. MAIN RESULTS: Sixty adult patients aged 14-91 y (median 62) received 1-69 units (median 4 units [1 unit = 12.5 g albumin]) and 470 total units. Surgical services prescribed albumin in 73 percent and medical services in 27 percent of the patients. Common indications for albumin included volume expansion (65 percent), as intraoperative fluid (13 percent), and to increase urine output (10 percent). The pharmacy computer system identified 63 percent of the patients. Of these, 13 percent were not billed for albumin they received. Examinations of patient billing statements found that up to $17,740 a year (15 percent) of albumin administered is not billed. The floor-stock distribution system used in the intensive care units contributed to most errors. CONCLUSIONS: Recommendations addressing the problems identified in this audit were made to the pharmacy, medical, nursing, and billing departments. Guidelines for albumin use were formulated and approved by the hospital's pharmacy and therapeutics committee.

The use of albumin in clinical practice.

The use of albumin in the clinical setting continues to generate controversy. Periodic shortages and the high cost of albumin have compelled many hospitals to develop guidelines regarding albumin administration. Our purpose is to review the human studies involving albumin. Particular emphasis will be placed on comparative trials involving albumin and the less expensive crystalloid solutions. It is hoped that this review will assist the clinician in making judgements concerning the appropriate use of albumin.