Adjunctive Use of Ketamine for Benzodiazepine-Resistant Severe Alcohol Withdrawal: a Retrospective Evaluation.

INTRODUCTION: Benzodiazepine (BZD)-resistant alcohol withdrawal remains a challenge for most institutions due to limited evidence with available agents. One published study currently exists utilizing the N-methyl-D-aspartate antagonist, ketamine, for alcohol withdrawal. OBJECTIVE: The purpose of our study was to evaluate the effect of adjunctive ketamine continuous infusion on symptom control and lorazepam infusion requirements for BZD-resistant alcohol withdrawal patients in the intensive care unit. METHODS: A retrospective review was conducted of patients receiving ketamine adjunctively with a lorazepam infusion for severe alcohol withdrawal between August 2012 and August 2014. Outcomes included time to symptom control, lorazepam infusion requirements, ketamine initial and maximum daily infusion rates, and adverse effects of ketamine. RESULTS: Thirty patients were included in the analysis. Mean time to initiation of ketamine after the initiation of a lorazepam infusion was 41.4 h. All patients achieved initial symptom control within 1 h of ketamine initiation. Median initial ketamine infusion rate was 0.75 mg/kg/h and the average maximum daily rate was 1.6 mg/kg/h. Significant decreases in lorazepam infusion rates from baseline were observed at 24 h (- 4 mg/h; p = 0.01) after ketamine initiation. No patients experienced documented CNS adverse effects. Two patients experienced hypertension and no patients experienced tachycardia related to ketamine. CONCLUSION: Adjunctive ketamine could provide symptom control for BZD-refractory patients and may potentially reduce lorazepam infusion requirements. Future studies to determine optimal dosing, timing of initiation, and place in therapy for BZD-resistant alcohol withdrawal are needed. The mechanism of action via the NMDA receptor with ketamine may provide benefit for BZD-resistant alcohol withdrawal.

Salicylate Toxicity from Genital Exposure to a Methylsalicylate-Containing Rubefacient.

Methylsalicylate-containing rubefacients have been reported to cause salicylate poisoning after ingestion, topical application to abnormal skin, and inappropriate topical application to normal skin. Many over-the-counter products contain methylsalicylate. Topical salicylates rarely produce systemic toxicity when used appropriately; however, methylsaliclyate can be absorbed through intact skin. Scrotal skin can have up to 40-fold greater absorption compared to other dermal regions. We report a unique case of salicylate poisoning resulting from the use of a methylsalicylate-containing rubefacient to facilitate masturbation in a male teenager. Saliclyate toxicity has not previously been reported from the genital exposure to methylsaliclyate.

Penile angioedema developing after 3 years of ACEI therapy.

BACKGROUND: Angiotensin-converting enzyme inhibitor-related angioedema (ACEI-RA) is a well-described condition, yet isolated genital ACEI-RA is a little-known entity. OBJECTIVE: A case of isolated genital angioedema is presented with photographic documentation. Possible complications and therapeutic options are discussed. CASE REPORT: A 71-year-old man presented with painless, nonpruritic genital swelling of 4 h duration. Medical history included peptic ulcer disease, hypertension, and benign prostatic hypertrophy. His medications included pantoprazole, hydrochlorothiazide, and lisinopril, which he had been taking for 3 years without any recent change in dosing. He was otherwise asymptomatic and previously had been in good health generally. The physical examination was positive only for diffuse, soft, nonpitting edema isolated to the scrotum and uncircumcised penis. The foreskin was only partially retractable. Urinalysis was normal. All symptoms resolved without complications within 48 h of discontinuing lisinopril and had not recurred at follow-up 4 months later. All cases of ACEI-RA isolated to the genitals that have been reported in the literature resolved without complications. CONCLUSIONS: ACEI-RA can present as isolated swelling of the genitals and is a potential cause of genital swelling. Patients who have no evidence of airway compromise, paraphimosis, or urinary retention from complications such as phimosis can be safely discharged with instructions to discontinue the offending agent and to return in case of development of the aforementioned conditions.