Clozapine-Induced Severe Toxicity: Exploring the Pharmacokinetic Profile of Clozapine and Its Significance in Hemodynamic Instability - A Case Report.

Hemodynamic instability in patients with clozapine intoxication can indirectly reflect the serum concentration of clozapine.We have described a case of a 32-year-old pregnant woman who developed life-threatening clozapine toxicity at 28 weeks of gestation. The levels of clozapine and norclozapine in the serum were high. We initiated hemoperfusion(HP) and other detoxification therapies to remove the drug. The patient had severely dilated peripheral blood vessels, which led to cardiac symptoms such as fatal hypotension and uncontrollable tachycardia, resulting in very high cardiac output and elevated Central venous oxygen saturation (ScvO2). Pharmacological intervention significantly improved the hemodynamics.In light of our observations in the ongoing case, we posit that evaluating hemodynamic parameters before and after blood detoxification could serve as a valuable means to gauge effectiveness and provide guidance for treatment.

Epidemiological and clinical characteristics and risk factors for death of patients with avian influenza A H7N9 virus infection from Jiangsu Province, Eastern China.

BACKGROUND: A novel avian influenza A (H7N9) virus has caused great morbidity as well as mortality since its emergence in Eastern China in February 2013. However, the possible risk factors for death are not yet fully known. METHODS AND FINDINGS: Patients with H7N9 virus infection between March 1 and August 14, 2013 in Jiangsu province were enrolled. Data were collected with a standard form. Mean or percentage was used to describe the features, and Fisher's exact test or t-test test was used to compare the differences between fatal and nonfatal cases with H7N9 virus infection. A total of 28 patients with H7N9 virus infection were identified among whom, nine (32.1%) died. The median age of fatal cases was significant higher than nonfatal cases (P<0.05). Patients with older age were more strongly associated with increased odds of death (OR = 30.0; 95% CI, 2.85-315.62). Co-morbidity with chronic lung disease and hypertension were risk factors for mortality (OR = 14.40; 95% CI, 1.30-159.52, OR = 6.67; 95% CI, 1.09-40.43, respectively). Moreover, the presence of either bilateral lung inflammation or pulmonary consolidation on chest imaging on admission was related with fatal outcome (OR = 7.00; 95%CI, 1.10-44.61). Finally, dynamic monitoring showed that lymphopenia was more significant in fatal group than in nonfatal group from day 11 to week five (P<0.05). The decrease in oxygenation indexes were observed in most cases and more significantly in fatal cases after week three (P<0.05), and the value of nearly all fatal cases were below 200 mmHg during our evaluation period. CONCLUSIONS: Among cases with H7N9 virus infection, increased age accompanied by co-morbidities was the risk of death. The severity of lung infection at admission, the persistence of lymphocytopenia, and the extended duration of lower oxygenation index all contributed to worsened outcomes of patients with H7N9 virus infection.

[Effects of lung recruitment maneuver on oxygenation and hemodynamics after open endotracheal suctioning in acute respiratory distress syndrome].

OBJECTIVE: To evaluate the treatment value of lung recruitment (LR) maneuver on oxygenation and hemodynamics in acute respiratory distress syndrome (ARDS) patients after open endotracheal suctioning (ETS). METHODS: Twenty ARDS/acute lung injury (ALI) patients requiring mechanical ventilation support were randomized into two groups after stabilizing for 30 minutes. Group 1: LRs were performed immediately after ETS (ETS+LR), and then ETS was repeated after 60 minutes without LR. Group 2: the first ETS was performed without LR (ETS-LR), and the second ETS was combined with LR after 60 minutes. Partial pressure of oxygen in artery (PaO(2)), central venous pressure (CVP), heart rate (HR) and mean arterial pressure (MAP) were serially measured during the procedure. RESULTS: The hemodynamic parameters were stable in all patients, and no arrhythmia occurred. PaO(2) decreased significantly after ETS, but recovered rapidly in 5 and 15 minutes after LR (both P<0.05). CONCLUSION: LR is effective in rapidly counteracting the deterioration in PaO(2) caused by open ETS in ARDS/ALI patients without interfering the hemodynamics.