[Systemic and local reactions in leg phlebography with special reference to iodine-containing contrast media. Randomized, prospective, intraindividual double-blind study using iodine-containing contrast media of different osmolarity and iodine concentration. I]

Iopamidol, a non-ionic, tri-iodinated radiographic contrast medium, was superior to the ionic substances ioxaglate, ioglicinate and ioxitalamate in the ascending phlebography. In 180 examinations on 90 patients (report I), which were carried out intraindividually by double blind technique, distinct differences were recorded in particular at pain registration. Since iopamidol was well tolerated in nearly all cases, pain was registered in 10% in ioxaglate, in 22% in ioglicinate and in 37% in ioxitalamate. Anaphylactoid reactions had been observed in one case (1.1%) with iopamidol, in 7% with ioglicinate, in 10% with ioxitalamate and in 17% with ioxaglate. The low incidence of clinically manifest postphlebographic thrombophlebitis and deep venous thrombosis was surprising. In no case was deep venous thrombosis seen after the application of low-osmolar substances, whereas transitory superficial vein irritations could be observed more frequently (10% in iopamidol and 21% in ioxaglate). In ioglicinate as well as in ioxitalamate one deep vein thrombosis and in 10% resp. 30% superficial thrombophlebitis were recorded.

Incidence and extent of venous sequelae with intravenous diazepam utilizing a standardized conscious sedation technique. Part II: Effects of injection site

The effects of site of venipuncture on the incidence of venous sequelae, utilizing a standard protocol, were assessed on 48 human subjects. Data were also recorded based on various demographic and clinical variables, including age, sex, race, vein diameter, dose, procedure time, IV fluid volume, injection pain and initial blood flow velocity. When the site of venipuncture was the antecubital fossa there was a significantly lower incidence of venous sequelae than when the venipuncture site was the dorsum of the hand, with the significant variables being venous diameter and procedure time. These findings further support the antecubital fossa as a preferred venipuncture site to the dorsum of the hand; however, there was a sufficient incidence of venous complications (37%) when the antecubital fossa was used to warrant consideration of contributory factors other than site. It appears that time of continuous infusion is a critical element and should be kept at a minimum. Also, subjects in whom Valium was injected demonstrated significantly more venous sequelae than those in whom 5% dextrose in water was injected, confirming previous reports that diazepam is irritating to the endothelial lining and thus is thrombogenic.

Venous complications of intravenous diazepam

In an attempt to clarify the confusion about venous complications from intravenous diazepam, a study of 2,468 consecutive oral surgery and general dentistry cases in which diazepam was used was undertaken. It was found that 7.9% of the patients experienced local phlebitis and 4.5%, thrombophlebitis during the week after the injection. These findings were correlated with age, weight, sexual gender, dosage, type and duration of procedure, and degree of apprehension experienced by the patient.

Prevention of lidocaine-infusion phlebitis by heparin and hydrocortisone

Previous reports have suggested that infusions of lidocaine (lignocaine) cause a high incidence of phlebitis. We investigated the possibility of reducing this high incidence by the addition of small amounts of heparin or hydrocortisone (or both) to the infusate of lidocaine. One hundred patients with acute myocardial infarction who were to receive a 48-hour prophylactic infusion of lidocaine (2.25 mg/min) were randomized to have one of the following added to their infusate in double-blind fashion: (1) placebo; (2) heparin (4,000 units/24 hr); (3) hydrocortisone (20 mg/24 hr); or (4) heparin and hydrocortisone. After 48 hours the incidence of phlebitis was 94 percent in the control group but only 41 percent in the group receiving heparin and hydrocortisone (p less than 0.005). Had the infusion been stopped after 24 hours, the incidence of phlebitis would have been 56 percent in the group receiving placebo, but only 19 percent in the drug-treated groups (p less than 0.01). We conclude that infusion of lidocaine causes a high incidence of phlebitis which can be markedly reduced by adding heparin or hydrocortisone (or both) to the infusate and limiting the duration of the infusion in a given vein to 24 hours.

[Etomidate in Intralipid. A solution for pain-free injection]

A new formula for solution of etomidate has been studied. Like other lipophilic drugs etomidate may be dissolved in a non-irritating oil emulsion and used for intravenous injection. Etomidate in Intralipid was compared as induction agent with etomidate in glycolic solution (Hypnomidate) and with methohexitone (Brietal). No pain on injection occurred when etomidate/Intralipid was used.

Venous complications of two diazepam preparations related to size of vein

The venous complications associated with the administration of two preparations of diazepam, an aqueous (Valium) or a lipid (Diazemuls) preparation were investigated in 100 patients before upper gastrointestinal endoscopy in a double-blind randomized study. No differences in pain during injection or subsequent thrombophlebitis were found when a large vein was used for the injections. In a retrospective study of 78 patients who had received either preparation in a vein on the dorsum of the hand, the frequency of thrombophlebitis was significantly less with the lipid preparation. Both preparations provided effective sedation for endoscopy.

Chemohormonal therapy of metastatic prostate cancer. A pilot study

Combined chemohormonal therapy of metastatic prostate cancer has not been previously evaluated in patients failing primary hormones (estrogens and/or orchiectomy). The combination of Adriamycin and high-dose diethylstilbestrol diphosphate (Stilphostrol) was studied in 19 heavily pretreated patients, to document toxicity and patient acceptability. Major toxicity was myelosuppression, cardiac failure and venous thrombosis. Clinical improvement was noted in 10/16 (63%) of evaluable patients. Patients with pre-existing cardiac disease or venous thrombosis are not suitable for this therapy.

Ceftazidime in severe infections: a Swiss multicentre study

A total of 105 patients (mean age 57, range 15 to 90) with serious infections were treated with intravenous ceftazidime, usually 2 g 8-hourly. Most patients had complicating factors such as major surgery, cancer, chronic obstructive lung disease, catheters or anatomical abnormalities. Eighty-seven infectious episodes in 77 patients could be assessed for efficacy. Bacteraemia was diagnosed in 26% of these episodes. Seventy-five per cent of infections were due to Gram-negative bacteria, Pseudomonas aeruginosa being the most frequent. The major sites of infections were the lower respiratory tract (30), the urinary tract (28), the soft tissues (9), the biliary tract (4), bones (4) and the ears (4). Overall, 67% of the patients were cured, 20% improved, 7% relapsed and 6% failed to respond. Among the 27 infections due to Ps aeruginosa, only two failures (in the same patient) and four relapses were recorded. However, in the two failures and in three other cases with persistent Ps. aeruginosa colonisation, the organism had become resistant to ceftazidime. Three failures were recorded in the seven Staphylococcus aureus infections included in this study. Superinfection occurred in four patients. Adverse events included rash (6), Clostridium difficile toxin-induced diarrhoea (3), transaminase elevation (3), weakly positive Coombs test (10). Ceftazidime appears to be safe and effective for the treatment of severe Gram-negative infections, including those caused by Ps. aeruginosa.

Ceftazidime in clinical practice

In an open trial, the efficacy of intravenously administered ceftazidime was evaluated in 106 adult patients with urinary or respiratory tract infections, soft tissue infections, osteitis and septicaemia. The most commonly isolated pathogens were Escherichia coli, Pseudomonas spp. and Staphylococcus aureus. Of 85 organisms isolated before treatment, 79% were cleared and 15% were cleared but later relapsed often because of the underlying conditions. Clinical cure was achieved in 70%, improvement occurred in 25% of the patients and 6% failed to respond. Marked increases in serum creatinine occurred in three patients with pre-existing renal impairment treated with ceftazidime in unmodified dosage. Exanthema, diarrhoea or local thrombophlebitis was noted in 13 patients.

Treatment of serious obstetric and gynecologic infections with cefoxitin

In order to evaluate the efficacy of cefoxitin, 25 patients with serious pelvic infections admitted to a community hospital were treated with the drug. Twenty-one patients (84%) responded to this therapy. Three of the four failures (75%) had a pelvic abscess. Resistant organisms included Staphylococcus aureus, Pseudomonas aeruginosa and enterococci. The adverse reactions encountered were due to localized phlebitis, which occurred in three patients (12%). The study demonstrated that cefoxitin was successful as a single agent in the treatment of serious soft-tissue pelvic infections.

Contrast agent-induced thrombophlebitis following leg phlebography: meglumine loxaglate versus meglumine lothalamate

A comparison was made of the incidence of venous thrombophlebitis resulting from the use of a high-osmolality contrast medium (Conray 60%, meglumine ioxaglate) and a low-osmolality contrast medium (Hexabrix 59%, meglumine iothalamate). In 30 patients with varicose veins, Conray was injected into one leg and Hexabrix into the other. The incidence of thrombophlebitis was then determined using the iodine-125 fibrinogen uptake test in a prospective, randomized, double-blind study. There was significantly less thrombophlebitis with Hexabrix than with Conray and the authors conclude that Hexabrix is safer for phlebography. Hexabrix is also stable in solution, only slightly more expensive than Conray, and one fifth the cost of metrizamide.

Thrombosis following phlebography with high-osmolar and low-osmolar contrast media

In a prospective, randomised double blind study of 47 phlebographies, diatrizoate and ioxaglate were compared with regard to possible postphlebographic thrombosis proved by 125I-Fibrinogen uptake test. A significantly lower rate of postphlebographic thrombosis was registered when the low-osmolar ioxaglate was used.

Effects of large doses of phenylbutazone administration to horses

The effects of large doses of phenylbutazone were evaluated in clinically normal horses. The drug was given to 4 groups of 2 horses each at the rate of 30 mg/kg of body weight, orally, or 30, 15, or 8 mg/kg IV daily for up to 2 weeks. All horses became anorectic and depressed after 2 to 4 phenylbutazone treatments, and the horses given 15 or 30 mg/kg died on or between days 4 and 7 of treatment. A decrease in total blood neutrophil count occurred in all horses, and was associated with toxic left shift in horses given the 2 larger dosage schedules. The horses also had progressive increases in serum urea nitrogen, creatinine, and phosphorus concentrations, accompanied by decreasing serum calcium concentrations. There was a progressive decrease in total serum protein in all 8 horses. Gastrointestinal ulcerations, renal papillary necrosis, and vascular thromboses were the predominant postmortem findings.

New drugs--boon or bane? Premedication and intravenous induction agents

Research on the benzodiazepines has shown that they have certain advantages over the opiates as premedicants. Diazepam, which produces good tranquilization, is well absorbed when given orally though absorption is influenced by other drugs given at the same time. Oral lorazepam leads to more prolonged sedation and amnesia but the final elimination is more rapid. Several new intravenous anaesthetics have been introduced during the last five years but none seems likely to replace thiopental. The theoretical disadvantages of thiopental are offset by its water-solubility, and the use of Cremophor EL in preparations of propanidid, alphaxalone, di-isopropyl phenol and one preparation of diazepam has led to many hypersensitivity reactions. Ketamine is gradually finding its rightful place in anaesthesia but its use is becoming limited to anaesthesia in difficult circumstances. The future concomitant use of other drugs and separation of isomers of ketamine may again broaden its applications. The new water-soluble steroid minaxolone has its own disadvantages, and the water-soluble benzodiazepine midazolam is as unpredictable for induction of anaesthesia as diazepam.

Nitrogen mustard therapy in children with frequent-relapsing nephrotic syndrome and steroid toxicity

Nitrogen mustard (HN-2) is an alkylating agent known to be effective in inducing and prolonging remissions of nephrotic syndrome in children. The fact that the drug is administered intravenously eliminates the problem of compliance, and the fact that the treatment needs to be given only for a few days may lower the incidence of side-effects observed with other cytotoxic agents. We administered HN-2 to 12 children with the steroid-sensitive frequent-relapsing form of nephrotic syndrome, who had evidence of steroid toxicity. Life table analysis reveals a 46% sustained remission rate after 27 mo of follow-up. Complications of HN-2 treatment included only mild thrombophlebitis (2 patients) and mild local paresthesia (1 patient).

Recurrence of intravenous-diazepam-induced phlebitis from oral diazepam

A patient who developed phlebitis from the intravenous administration of diazepam is described. This episode resolved in two days after treatment with moist heat packs. Three days after complete resolution, the phlebitis recurred approximately eight hours after a single oral dose of diazepam. This recurrence of phlebitis resolved slowly over seven days, with warm soaking and aspirin therapy. Oral diazepam may have exacerbated the initial phlebitis by interfering with a subclinical healing process.

Superior sagittal sinus thrombosis associated with androgen therapy for hypoplastic anemia

Of 27 patients with hypoplastic anemia treated between 1971 and 1974 with male hormone and protein-assimilating hormone, 3 developed superior sagittal sinus thrombosis (SSST). The clinical symptoms and signs and angiographic findings of SST were characteristic enough to allow an early diagnosis. Signs related to SST were seizures, hemiplegia, facial palsy, stupor, and coma, with the most important prodrome and consistent subjective complaint being headache. Following discontinuation of the hormone therapy, neurological signs and symptoms related to SSST gradually subsided. In all cases, the hematological picture improved with discontinuation of the hormone therapies. It appears that administration of male hormone can be associated with the development of SSST. If neurological symptoms and signs of SSST appear, administration of the hormones should be discontinued.

Incidence and extent of venous sequelae with intravenous diazepam utilizing a standardized conscious sedation technique

Twenty-four periodontal patients volunteered for a study designed to investigate the incidence of venous sequelae with Injectable Valium administered by a standardized conscious sedation technique. Sedative doses were injected into veins on the dorsum of the hand utilizing a continuous infusion drip of 5% dextrose in water. Postoperative evaluation extended over 12 weeks. Ultrasonic tests for thrombosis were performed with a Doppler Flowmeter. Independent variables considered included age, vein size, volume of drug, volume of intravenous solution, pain upon injection and initial venous flow velocity. Sixteen subjects (66.67%) experienced some form of venous sequelae. Thirteen sequelae advanced to thrombophlebitis. Those subjects who demonstrated no complications had significantly higher initial venous flow than those with complications. Those subjects with resolution of complications demonstrated a significantly greater initial venous flow than those without resolution of complications. Clinical variables of pain on injection, vein diameter, dose of diazepam and volume of infusion solution did not significantly differ across groups. However, those subjects with no complications were significantly older than those with complications. It is recommended that the larger veins of the forearm and antecubital fossa, with greater mean velocities of venous flow, be preferred for intravenous diazepam administration to attempt to decrease the nature and incidence of thrombophlebitis.