Carbonate chemistry and carbon sequestration driven by inorganic carbon outwelling from mangroves and saltmarshes.

Mangroves and saltmarshes are biogeochemical hotspots storing carbon in sediments and in the ocean following lateral carbon export (outwelling). Coastal seawater pH is modified by both uptake of anthropogenic carbon dioxide and natural biogeochemical processes, e.g., wetland inputs. Here, we investigate how mangroves and saltmarshes influence coastal carbonate chemistry and quantify the contribution of alkalinity and dissolved inorganic carbon (DIC) outwelling to blue carbon budgets. Observations from 45 mangroves and 16 saltmarshes worldwide revealed that >70% of intertidal wetlands export more DIC than alkalinity, potentially decreasing the pH of coastal waters. Porewater-derived DIC outwelling (81 ± 47 mmol m-2 d-1 in mangroves and 57 ± 104 mmol m-2 d-1 in saltmarshes) was the major term in blue carbon budgets. However, substantial amounts of fixed carbon remain unaccounted for. Concurrently, alkalinity outwelling was similar or higher than sediment carbon burial and is therefore a significant but often overlooked carbon sequestration mechanism.

Inappropriate medication administration practices in Canadian adult ICUs: a multicenter, cross-sectional observational study.

BACKGROUND: Critically ill patients often receive multiple medications via continuous intravenous infusion. Coadministration of multiple medications through the same port of a venous access device often is necessary but requires an assessment of compatibility. OBJECTIVE: To describe the frequency of inappropriate coadministration of continuously infused medications via a Y-site and the use of intravenous catheters in patients in Canadian intensive care units (ICUs) in a multicenter, cross-sectional observational study. METHODS: Data pertaining to medication compatibility via Y-site infusion (medication combinations known to be incompatible or not known to be compatible), frequency of specific medications administered via continuous infusion, and catheter use (median number, location, and types of venous catheters) were collected from medical records of 434 patients in the ICUs of 13 teaching hospitals in Canada. RESULTS: Forty-six percent of patients were receiving 2 or more medication infusions simultaneously. Forty episodes of inappropriate coadministration of these infusions were identified in 37 patients. The prevalence of inappropriate coadministration of drugs via a Y-site port in all patients was 8.5% (95% CI 5.8-11.2). The prevalence of incompatible combinations via Y-site in patients with 2 or more medication infusions was 18.7%. Twenty-five of these 37 patients could have had their drug schedules rearranged into acceptable combinations, leaving 12 patients who would have required additional intravenous access to facilitate appropriate medication infusions. Median (range) number of central and peripheral venous access devices inserted per patient were 1 (0-4) and 1 (0-5), respectively. Seventeen of 95 patients with 2 or more central venous catheters could have had their medication infusions rearranged to render 1 catheter idle. CONCLUSIONS: Inappropriate Y-site combinations of medications continuously infused in Canadian ICUs are common. Management of medication infusions could, however, have been optimized in most of these situations.

Stability of venlafaxine immediate-release suspensions.

Venlafaxine is a novel antidepressant that works by inhibiting the reuptake of serotonin and norepinephrine. The objectives of this study were to reformulate a venlafaxine extended-release suspension into an immediate-release preparation and then determine the physical and chemical stability of the new venlafaxine formulation. Suspensions of venlafaxine (75mg/5mL) were prepared from extended-release microspheres that had been reduced to powder and then dispersed in either OraPlus/OraSweet (50:50) or simple syrup. Triplicate samples of the suspensions were collected from amber plastic bottles stored at either 5 degrees C or 23 degrees C on days 0, 7, 14, 21, and 28, and assayed. Physical stability was based on color and pH changes. A validated high performance liquid chromatography assay method was used to determine the chemical stability of the active ingredient. This study found that venlafaxine immediate-release suspensions, prepared in either OraPlus/OraSeet or simple syrup, are physically and chemically stable for 28 days when stored in amber plastic bottles at either 5 deg C or 23 deg C.

Systematic review of physical and chemical compatibility of commonly used medications administered by continuous infusion in intensive care units.

OBJECTIVE: To quantify the physical and chemical stability data published for commonly used continuously infused medications in the intensive care unit and to evaluate the quality of the studies providing these data. DATA SOURCES AND STUDY SELECTION: We conducted a systematic electronic literature search of MEDLINE, EMBASE, and International Pharmaceutical Abstracts as well as the references of electronic drug compatibility textbooks for all English and French language research publications evaluating the physical compatibility or chemical stability of the 820 possible two-drug combinations of 41 commonly used drugs in an adult intensive care unit. DATA EXTRACTION AND SYNTHESIS: A total of 93 studies comprised of 86 (92%) studies evaluating physical compatibility and 35 (38%) studies evaluating chemical compatibility of at least one drug combination of interest were included. Physical and/or chemical compatibility data exist for only 441 of the possible 820 two-drug combinations (54%), whereas chemical compatibility data exist for only 75 (9%) of the possible combinations. Of the 441 combinations for which compatibility data are available, 67 (15%) represent incompatible combinations and 39 (9%) had conflicting data in which both compatible and incompatible data were identified. CONCLUSIONS: Physical compatibility studies that provide the basis for y-site compatibility are lacking for commonly used medications in intensive care unit patients and may contribute to unsafe medication practices. Furthermore, the heterogeneity in the methodology of these studies likely contributes to the common finding of conflicting data for specific combinations of drugs. Future studies should apply similar methodologic and reporting principles to be able to reproduce and compare outcomes both clinically and in the laboratory.

Efficiency and safety of a standardized protocol for intravenous insulin therapy in ICU patients with neurovascular or head injury.

BACKGROUND: To evaluate the safety and efficiency of a protocol for glycemic control in intensive care unit (ICU) patients with neurovascular or head injury. METHODS: Two cohorts of 50 consecutive patients admitted to the ICU with an admission diagnosis of neurovascular or head injury before and after protocol implementation were evaluated. All patients in the interventional cohort received insulin using a standardized intravenous insulin infusion protocol targeting blood glucose levels of 7-9 mmol/l. Efficiency (time to reach and time within target range), safety (hypoglycemia), and nursing compliance (protocol violations) were evaluated. RESULTS: The median time to reach the target blood glucose range was shorter in the interventional cohort than the conventional cohort (5.0 h [0.5-20.5 h] vs. 12.9 h [1.3-90.3 h]; P < 0.001). More time was spent within target range in the interventional cohort than in the conventional cohort (36.4 +/- 16.3% vs. 27.1 +/- 19.0%; P < 0.001). The median prevalence of mild (<4.9 mmol/l) hypoglycemia (0 [0-1.11]% vs. 0.58 [0-2.79]%; P < 0.001) and moderate (<3.9) hypoglycemia (0[0-0.55]% vs. 0 [1-1.25]%; p < 0.001) was significantly lower in the interventional cohort. CONCLUSIONS: The intravenous insulin infusion protocol improved the safety and efficiency of glycemic control for ICU patients with neurovascular or head injury.

Antimicrobials in acute exacerbations of chronic obstructive pulmonary disease - An analysis of the time to next exacerbation before and after the implementation of standing orders.

OBJECTIVE: To compare the mean time to next exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) before and after the implementation of standing orders. SETTING: Tertiary care hospital, Halifax, Nova Scotia, Canada. POPULATION STUDIED: The records of 150 patients were analyzed, 76 were in the preimplementation group, 74 in the postimplementation group. INTERVENTION: The management and outcomes of patients admitted with an acute exacerbation of COPD before and after the implementation of standing orders were compared. DESIGN: A retrospective chart review. MAIN RESULTS: THERE WAS NO DIFFERENCE IN THE MEAN TIME TO NEXT EXACERBATION BETWEEN TREATMENT GROUPS (PREIMPLEMENTATION GROUP: 310 days, postimplementation group: 289 days, P=0.53). Antibiotics were used in 90% of the cases (preimplementation group: 87%, postimplementation group: 93%). The postimplementation group had a 20% increase in the use of first-line agents over the preimplementation group. Overall, first-line agents represented only 37% of the antibiotic courses. CONCLUSIONS: The implementation of standing orders encouraged the use of first-line agents but did not influence subsequent symptom resolution, length of hospital stay, or the infection-free interval in patients with acute exacerbations of COPD.