Five years of therapeutic drug monitoring in the intensive care did not change vancomycin prescription behaviour: perceived needs for decision support.

BACKGROUND: This study aims to assess clinicians' behaviour in prescribing vancomycin in the Intensive Care Unit (ICU) and their adherence to local guidelines for therapeutic drug monitoring (TDM). METHODS: In this observational cohort study we included all consecutive patients admitted to a 28-bed multidisciplinary mixed adult ICU of a large university hospital in Amsterdam between January 2002 and September 2007 who were prescribed vancomycin for ≥ 3 days. We measured guideline adherence by checking for each given advice the corresponding action and monitored adherence over time using Statistical Process Control. RESULTS: In 475 patients prescribed vancomycin, 1336 serum concentrations were measured, of which 598 in time and 738 with a median delay of 31 hours. Dose or dose frequency adjustments were often not done (54% in advice 2 [half dose frequency] and 86% in advice 4 [increase dose with 50%]) or not done concordantly (32% in advice 2 [half dose frequency] and 60% in advice 7 [half dose frequency if trough serum concentration]). Although adherence was stable over time, the average level was low (58.7%). CONCLUSION: Five years of TDM did not achieve the desired prescription behaviour in the ICU and clinicians feel there is a need for computerized decision support. Local projects should measure adherence and implement appropriate solutions.

Cyclosporine-induced anaphylaxis.

OBJECTIVE: To describe a case of an anaphylactic reaction after first ingestion of oral cyclosporine capsules (Neoral). CASE SUMMARY: A 73-year-old white woman was admitted for the treatment of metastatic breast carcinoma with an experimental oral paclitaxel solution in combination with cyclosporine capsules. After ingestion of the cyclosporine capsules, the patient collapsed within one hour. She initially experienced severe hypotension and bradycardia. After a few minutes, she developed severe tachycardia, dyspnea, and decreased consciousness. Administration of epinephrine, dexamethasone, clemastine, oxygen, and gelofusine (succinylated gelatin 4% in NaCl 0.9%) infusion resulted in complete recovery after several hours. The planned oral paclitaxel administration was canceled. Intravenous paclitaxel was given the next day, preceded by standard premedication with dexamethasone, clemastine, and cimetidine, without complications. DISCUSSION: To our knowledge, this is the first report in the literature of an anaphylactic reaction after oral ingestion of cyclosporine capsules. Earlier reports of anaphylaxis concerned intravenous cyclosporine or oral solutions of cyclosporine (both Sandimmune). These anaphylactic reactions were considered to be due to the pharmaceutical vehicle Cremophor EL or related substances, which are well-known causes of anaphylaxis. The capsules used in this case contain the Cremophor EL-related polyoxyl 40 hydrogenated castor oil as a base; our patient's anaphylactic shock may have been due to this substance. CONCLUSIONS: In addition to earlier reports about anaphylactic reactions after administration of an intravenous or oral solution of cyclosporine, this case shows that anaphylactic shock can occur after ingestion of cyclosporine capsules.

Clinical research on antiangiogenic therapy.

A promising novel target for anti-cancer therapy is the tumour vasculature. Both primary tumour growth and the formation of metastasis depend on the establishment of new blood vessels from preexisting ones, a process called angiogenesis. Inhibition of angiogenesis and targeting of the tumour vasculature are highly effective in controlling tumour growth. Several natural and synthetic compounds have been developed and are currently tested in pre-clinical and clinical studies. This review intends to provide an overview of agents with antiangiogenic activity and the early clinical experience with these drugs.

The automatic implantable cardioverter defibrillator as a therapeutic modality for recurrent ventricular tachycardia: a case study.

Recurrent ventricular tachycardia and fibrillation is a life threatening occurrence for patients who have a history of sudden cardiac death, coronary heart disease, or cardiac dysfunction due to a variety of causes. Historically, anti-arrhythmic drug therapy has been the main therapeutic modality used to treat life threatening ventricular arrhythmias. However, some patients are refractory to these medications and suffer disturbing adverse reactions. During the last decade the Automatic Implantable Cardioverter Defibrillator (AICD) has been used to convert ventricular tachycardia and ventricular fibrillation, and limit the amount of medication needed to control their occurrence. This article presents a description of the AICD device followed by a case study which includes nursing diagnoses and interventions.