Failure to document.

The failure to adequately document events in the written clinical record is the major reason for letters of inquiry from Peer Review Organizations (PROs). The major causes of inadequate documentation are time pressures, the mind set of physicians, increasing subspecialization with the fragmentation of patient care, and a distrust of review activities in general. However, the accurate recording of medical events that ensue during the course of caring for patients is an integral aspect of the profession of medicine.

Isoproterenol in the treatment of shock due to bacteremia with gram-negative pathogens.

A series of 12 patients with shock that followed bacteremia due to gram-negative pathogens is presented, and a case is reported. The hemodynamic alterations that occur in such patients are discussed. Initial therapy includes intravascular volume expansion and administration of glucocorticoids and antibiotic drugs; subsequent therapy, if necessary, includes administration of metaraminol and isoproterenol respectively. The problems encountered with this method of treatment are described. The use of isoproterenol (2.5 to 5 mg. in 500 ml. of 5 per cent dextrose in water administered intravenously at a rate of 0.5 to 2.0 ml. per minute) is suggested to correct the hemodynamic alterations usually present and permit further expansion of circulating blood volume with reduced risk of acute circulatory overload. Clinical use of this drug is recommended because of its positive ionotropic effect on the myocardium (beta-adrenergic stimulation) and direct peripheral arterial vasodilator effect (alpha-adrenergic blockade) that act to correct the hemodynamic alterations usually present in man in endotoxin shock.