Emergency applications of intraosseous infusion

Vascular access is an important step in the care of the critically ill child but can be very difficult and time consuming. Recently, intraosseous infusion has experienced a resurgence as a rapid alternative to venous cannulation. Several cases illustrate the usefulness of this technique in the emergency department. Included are the first reports of the use of intraosseous diazepam and succinylcholine.

[Potentials of infusion therapy in enhancing the detoxification effect of hemosorption in patients suffering from suppurative-septic complications of mechanical injury]

Under study was the application of microvasoplegia as a method of preoperative management in fulfilling hemosorption in patients with pyo-septic complications of a severe mechanical trauma. The method of infusion and medicamentous therapy used before hemosorption is described. Laboratory examinations of the enzyme toxemia level have shown pathogenetic grounds of the complex method of treatment. Positive clinical results were obtained.

Treatment of rheumatoid arthritis with desferrioxamine

Desferrioxamine was used to treat six patients who had rheumatoid arthritis refractory to conventional treatment, on the basis that levels of intra-articular iron would be reduced and inflammation lessened. After a period of initial intensive treatment which was limited by side effects, five patients continued on once-weekly maintenance doses. Two patients had temporary improvement in their symptoms, but relapsed in spite of continuing treatment. The remaining three patients completed six months of treatment with no improvement in their rheumatoid disease. There were no significant changes in rheumatological parameters, immunological markers of disease activity nor radiological evidence of improvement. Treatment did lead to significant falls in haemoglobin concentration (p less than 0.01), mean corpuscular volume (p less than 0.05) and serum ferritin levels (p less than 0.02). Therefore, in spite of a reduction in iron available for haem synthesis and a fall in tissue storage iron the rheumatoid inflammatory process persisted.

Technical aspects of intraperitoneal chemotherapy in abdominal carcinomatosis

Between November 1983 and July 1985, 41 patients with abdominal carcinomatosis had peritoneal catheters surgically implanted for the purpose of intraperitoneal chemotherapy. Peritoneal fluid distribution was documented by computerized tomography examination prior to chemotherapy and was correlated with the surgical procedure performed and the pathological findings. In this series, peritoneal fluid distribution appeared to be an important prognostic factor in determining tumor response. The catheter-related complication rate was acceptable.

Percutaneous placement of a venous access port in a pediatric patient population

Venous access for administration of therapeutic agents and blood sampling has been difficult in the pediatric age group. A subcutaneous injection venous access port, the Infuse-A-Port (Infusaid Corp, Norwood, Mass) has been placed by percutaneous means in 29 patients aged 2 to 24 years. Placement has been under general (16) and local (13) anesthesia. There have been five problems (extravasation 2, suspected sepsis 1, and hematoma 2) during a total of 2,927 days of exposure. The convenience, reliability, safety, and patient acceptance of this venous access port makes this method the preferred choice for prolonged venous access in the pediatric age group.

Intraventricular therapy of cryptococcal meningitis via a subcutaneous reservoir

Intraventricular administration of amphotericin B for meningitis due to Cryptococcus neoformans is usually reserved for selected, seriously ill patients with recurrent disease. Between September 1973 and November 1983, 10 of 23 patients treated for cryptococcal meningitis at Memorial Sloan-Kettering Cancer Center received intraventricular amphotericin B through subcutaneous reservoirs, in addition to systemic therapy. The value of intraventricular amphotericin B was assessed in the 13 patients treated for first episodes of meningitis with systemic amphotericin B and flucytosine. Death during therapy occurred in one of six patients with intraventricular and systemic therapy compared with six of seven patients with systemic therapy alone (p = 0.025). The cerebrospinal fluid was sterilized in six of six patients given systemic and intraventricular therapy compared with three of seven given systemic therapy alone (p = 0.049), and the cerebrospinal fluid cryptococcal antigen titer declined in six of six patients given systemic and intraventricular therapy compared with two of seven given systemic therapy alone (p = 0.016). In the 10 patients who received intraventricular therapy, there were no complications related to reservoir insertion; however, complications related to reservoir use requiring replacement or revision occurred in two patients, and bacterial infection occurred in one but was treated successfully without removal of the reservoir. Although these data are retrospective, they suggest that early therapy with intraventricular amphotericin B in combination with systemic therapy may be beneficial and relatively safe in patients with cryptococcal meningitis and a poor prognosis.

The theory and practice of retrograde infusion: influence of tube diameter on drug delivery

This work identifies a model for the flow dynamics of retrograde drug infusion, thereby helping to clarify the influence of variables on drug dilution in the apparatus and hence drug infusion rate. The study is a 2(3) factorial design that focuses on the influence of tube diameter (0.065 vs. 0.120 inches) in conjunction with changes in injected drug volume (2.0 vs. 5.0 ml) and iv flow rate (2.0 vs. 10.0 ml h-1). Each of the three variables was shown to exert a statistically significant (p = 0.01) effect on the total volume of fluid necessary to clear a dose from the retrograde apparatus. In all cases studied, smaller diameter tubes, larger injected drug volumes, and slower iv flow rates decreased the total volume fraction (F0.95). Within the confines of the study, practitioners may use an F0.95 value of 1.5 to predict the time at which a patient's retrograde drug infusion is likely to be complete. This, in turn, may be used to facilitate proper timing of blood sampling for therapeutic drug monitoring as well as other pharmacokinetic manipulations.

[Continuous intravenous or intra-arterial administration via a subcutaneous implantable infusion chamber. Preliminary clinical experiences with particular reference to intra-arterial chemotherapy]

An infusion chamber was implanted subcutaneously in 18 patients for intravenous systemic treatment and in 20 for intra-arterial treatment of the liver. Intravenous catheters were introduced via the cephalic vein, intra-arterial ones via the gastroduodenal artery, after exclusion of extrahepatic metastases. Six manageable complications were observed during a total implantation time of 102 months for i.v. treatment and usage over 500 days: three temporary occlusions; one infection; two extravasations. The intra-arterial chemotherapy, largely for hepatic metastases of breast carcinoma, was undertaken according to a modified FAM schema (fluorouracil, adriamycin, mitomycin C): It achieved a high response rate with two full and eleven partial remissions. Complications were rare, except for 4 temporary occlusions. Systemic side effects were almost completely absent, local toxicity was low. One problem was the fixation of the needle which connects to the infusion chamber. This was true for both intravenous and intra-arterial treatment.

[Continuous subcutaneous deferoxamine infusions in thalassemia major. Improvement in glucose tolerance]

Exocrine and endocrine pancreatic functions were studied in 30 patients with homozygotic beta-thalassaemia. All were treated with continuous subcutaneous deferoxamine infusions for a mean period of 30 months. Three patients (aged 18-22 years) had insulin-dependent diabetes, two before and one shortly after the onset of deferoxamine administration. There was no improvement during the treatment. An abnormal glucose tolerance test was demonstrated in 14 patients (47%) before and in seven (23%) during deferoxamine infusion. Enzyme activity of alpha-amylase and lipase as an expression of exocrine pancreatic function was normal in all during the observation period. Improvement in endocrine pancreatic function was apparently age-dependent: the younger the patient at the onset of treatment the more likely is normalization of the oral glucose tolerance test.