Opioid versus Benzodiazepine-based Sedation for Mechanically Ventilated Patients in the Internal Medicine Ward.

BACKGROUND: Opioid-base sedation is considered the first line choice in ventilated patients in intensive care units (ICU). Few studies have examined sedation in ventilated patients outside the ICU. A pilot program was initiated in the internal medicine ward A at Meir Hospital in Kfar Saba, Israel. A new sedation protocol was implemented for opioid-based versus benzodiazepine-based sedation in ventilated patients. OBJECTIVES: To compare the rates and intensity of delirium between patients who received opioid-based sedation vs. benzodiazepine-based sedation. To compare parameters related to morbidity and mortality. METHODS: We conducted a retrospective before-after intervention study based on data collection. Patients who were admitted to the internal medicine ward A from January 2020 to January 2021 and required sedation and ventilation were included. Demographic data, medical history data, admission data, Richmond Agitation and Sedation Scale scores, hemodynamic parameters, reports of falls and self-harm, and data regarding unplanned extubation were collected, as well as the need for additional sedative drugs. RESULTS: Chronic hypertension was more common in the opioid group. Delirium intensity tended to be higher in the benzodiazepine group. The number of ventilation days was significantly higher in the benzodiazepine group, as was the number of times adjuvant sedation was required. CONCLUSIONS: Opioid-based sedation outside the ICU was associated with shorter ventilation days, tendency toward lower intensity of delirium, and reduction in requirement of adjuvant sedative drugs compared to benzodiazepine-based sedation. Further studies are required to confirm the findings.

Epidural vs. systemic analgesia in the Intensive Care Unit: retrospective study of patient outcomes.

BACKGROUND: Patients admitted to the Intensive Care Unit (ICU) often experience acute pain. Causes include major surgery, multisystem trauma, and pancreatitis. Most ICU patients who require pain management are treated with systemic analgesia, usually intravenous opioids. This study compared the rate of pain and delirium scores, as well as mortality and morbidity between ICU patients treated with systemic vs. epidural analgesia. METHODS: This retrospective analysis included patients who were in the ICU from January 2011 to June 2021, admitted due to thoracic, abdominal, pelvic, or lower limb surgery; pancreatitis; multiple rib fractures, or multisystem trauma. Data included demographics, admission parameters and indication, VAS score, Richmond Agitation and Sedation Score, in-hospital morbidity, and mortality, medical history, and medications. RESULTS: There was no significant difference in demographics, chronic medications, and past illness, excluding chronic obstructive pulmonary disease, peripheral vascular disease, and past cerebral vascular disease. ICU length of stay was shorter in the epidural group, but overall hospital length of stay was not. Except for increased need for dialysis in the systemic analgesia group, disease severity was similar in both groups. The epidural group had fewer days on mechanical ventilation and lower 28-day mortality, as well as fewer episodes of delirium, although pain scores were similar. There was no difference between groups in the need for physical restraints or antipsychotics for delirium. CONCLUSIONS: Epidural analgesia reduced the number of delirium events and was associated with a shorter ICU stay, fewer ventilation days and a lower mortality rate. Further research is needed to confirm these findings.

Sugammadex-Induced Anaphylactic Shock Reversed With Short-Term Continuous Veno-Venous Hemodiafiltration: A Case Report.

Anaphylaxis is a life-threatening, systemic, hypersensitivity reaction, manifested by urticaria, hypotension, and respiratory symptoms. Antigens that are cleared renally may have protracted exposure in patients with impaired renal function, resulting in prolonged and refractory anaphylactic shock. After administration of sugammadex, a 47-year-old man developed prolonged, refractory anaphylactic shock, with anuria due to acute kidney injury. The patient was treated with continuous, short-term, veno-venous hemodiafiltration. Initiating this therapy in patients with refractory anaphylactic shock and anuria due to an antigen that is excreted renally can expedite recovery.

Low molecular weight heparin for venous thromboembolism prophylaxis in general Intensive Care Unit patients: an anti-factor Xa level-based approach.

BACKGROUND: Venous thromboembolism (VTE) in the Intensive Care Unit (ICU) is associated with significant morbidity and mortality therefore prevention is imperative to reduce its burden. VTE prophylaxis in ICU patients is primarily pharmacological using low molecular weight heparin (LMWH). Plasma anti-factor Xa (anti-FXa) levels may be used to measure LMWH activity. This study aims to determine the proportion of acutely ill patients in a general ICU receiving standard VTE prophylaxis that achieve adequate peak or trough anti-FXa prophylactic levels and to determine the effect of LMWH dose adjustment in patients not achieving adequate anti-FXa prophylactic levels. METHODS: Peak and trough anti-FXa levels were measured at four and 23 hours respectively after receiving the second consecutive daily enoxaparin 40 mg sc injection. Patients in whom peak anti-FXa levels were found to be sub-prophylactic (<0.2 IU/mL), were dose escalated to enoxaparin 60 mg once daily. Peak and trough levels were repeated as above. RESULTS: Sixty-one percent of study patients (N.=46) were found to have sub-prophylactic peak anti-FXa levels. Twenty-seven patients received an increased enoxaparin dose of 60 mg/d. Of these, nine patients (33.3%) still failed to achieve the target prophylactic peak anti-FXa level (0.2-0.4 IU/mL). Male gender and high body mass index (BMI) were significantly and strongly correlated with sub-prophylactic anti-FXa levels. CONCLUSIONS: Most ICU patients in this study did not achieve recommended prophylactic anti-FXa levels while receiving a standard dose of enoxaparin and these levels failed to increase after enoxaparin dose escalation in a significant proportion of patients. High BMI and male gender are associated with sub-prophylactic levels of anti-FXa in critically ill patients.

Catastrophic anti-phospholipid syndrome with Libman-Sacks endocarditis following eltrombopag therapy for immune thrombocytopenic purpura: A case report.

BACKGROUND: Immune thrombocytopenic purpura (ITP) is an autoimmune disease, with accelerated destruction of platelets, estimated to affect 1.6-3.9 in 100,000 adults every year in the European Union. Glucocorticoids and intravenous immunoglobulins are common drug therapies. In refractory cases, drugs that enhance thrombopoiesis may be used. Eltrombopag is a thrombopoietin receptor agonist, known to increase platelet count in patients with refractory ITP. Thrombotic adverse events have been described in association with Eltrombopag administration. CASE REPORT: A young female patient of Ethiopian ancestry with systemic lupus erythematosus, triple Antiphospholipid (APLA) positive serology and refractory ITP who received Eltrombopag and 2 weeks later developed catastrophic APLA syndrome with severe Libman-Sacks endocarditis of the mitral and aortic valves, multiple intracerebral infracts and arterial thrombosis of the left upper limb. CONCLUSION: Eltrombopag is a salvage drug, used in refractory ITP. Thrombotic adverse events, some of which may be life-threatening, are a possible complication, especially in high-risk patients.

Soluble transferrin receptor as a diagnostic laboratory test for detection of iron deficiency anemia in acute illness of hospitalized patients.

BACKGROUND: Many patients in the internal medicine ward have anemia. The etiology for the anemia may be multifactorial and, in the setting of inflammatory process when the ferritin is increased, it is difficult to diagnose iron deficiency anemia. Soluble transferrin receptor (sTfR) had been suggested as an indicator for iron deficiency. No study has investigated the meaning of high sTfR as the only positive marker of iron deficiency anemia (IDA) caused by gastrointestinal tract (GIT) bleeding in hospitalized patients. OBJECTIVES: To demonstrate the importance of high levels of sTfR as a marker for further GIT investigation in cases of anemia where the level of ferritin was normal or increased. METHODS: We retrospectively assessed all patients in an internal medicine ward in our facility who had anemia, high sTfR levels (> 5.0 mg/L) and normal or high ferritin levels and who underwent esophagogastroduodenoscopy and colonoscopy. RESULTS: Of 32 patients with anemia and normal or high ferritin levels and high sTfR, 22 patients (68%) had findings that explained IDA (in some patients more than one finding). Those findings were colonic polyps (n=9), carcinoma of colon (n=4), duodenal ulcer (n=4), carcinoma of stomach (n=3), colitis (n=3), atrophic gastritis (n=1), erosive gastritis (n=1) and angiodysplasia (n=1). CONCLUSIONS: High sTfR may be a good indicator of IDA caused by GIT bleeding when the ferritin level is normal or high. GIT investigation is warranted in such cases.

Geoepidemiology of myasthenia gravis [corrected].

Myasthenia gravis (MG) is an autoimmune disease that affects the post-synaptic area of the neuromuscular junction. Its hallmark is weakness that worsens with activity. MG incidence is rising in the recent decades, mostly the late onset subtype, which is considered to be due to the aging population or unknown environmental factors. The disease has several subtypes which defer slightly in the clinical characteristics, immunological markers, population distribution and the suitable treatments. The autoimmune nature of the disease is manifested by a decrease in the number of acetylcholine receptors in the muscle receptors which makes the endplate potential to be lower than the threshold needed to activate muscle fiber action potential. In our review we try to find the environmental influence on the disease.