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Soleman SR, Adnan ML, Sudiarto HA, Mahathma SB, Tazkia AA, Firdaus HA, Khotijah AA, Pramaningtyas MD, Choironi EA. Effects of diethylene glycol contamination of pharmaceutical products on unexplained acute kidney injury in children: a systematic review. Clin Exp Pediatr 2024; 67:395-402. [PMID: 38186259 DOI: 10.3345/cep.2023.01039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/21/2023] [Indexed: 01/09/2024] Open
Abstract
Unexplained acute kidney injury (AKI) in children owing to diethylene glycol (DEG) contamination during drug production has gained attention in recent years. This qualitative study investigated the effects of DEG exposure on the incidence of unknown AKI in children. A systematic review following the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines was proposed to search for studies using predefined search terms in the PubMed, EBSCO, and Web of Science data-bases without publication date restrictions. The inclusion criteria are observational study, case study, case report, and case series design; and having provided accurate data for DEG poisoning and AKI diagnosis in children. All authors performed the study screening, data extraction, and data synthesis processes. Consensus was reached by mutual agreement. The data synthesis was conducted according to the DEG and unexplained AKI in children by examining the statistical data using Microsoft Excel 2017 and storing the data using the cloud service of Universitas Islam Indonesia. Of the 115 included studies, 21 met the inclusion criteria, including 2 case-control studies, 1 cross-sectional study, 4 case studies, and 14 case reports. DEG-contaminated paracetamol caused unexplained AKI in children. Other drugs including cough expectorants, antihistamines, and sedatives were administered. Chemicals other than DEG, such as propylene glycol and ethylene glycol, also induce AKI owing to overprescription and unintentional exposure. A recent epidemic of unexplained AKI showed contaminated paracetamol as the poisoning agent regardless of formula.
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Affiliation(s)
- Sani Rachman Soleman
- Department of Public Health, Faculty of Medicine, Universitas Islam Indonesia, Yogyakarta, Indonesia
| | | | | | | | - Alya Ayu Tazkia
- Faculty of Medicine, Universitas Islam Indonesia, Yogyakarta, Indonesia
| | | | | | | | - Emi Azmi Choironi
- Department of Pediatrics, Faculty of Medicine, Universitas Islam Indonesia, Yogyakarta, Indonesia
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2
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Scieszka DP, Garland D, Hunter R, Herbert G, Lucas S, Jin Y, Gu H, Campen MJ, Cannon JL. Multi-omic assessment shows dysregulation of pulmonary and systemic immunity to e-cigarette exposure. Respir Res 2023; 24:138. [PMID: 37231407 PMCID: PMC10209577 DOI: 10.1186/s12931-023-02441-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/01/2023] [Indexed: 05/27/2023] Open
Abstract
Electronic cigarette (Ecig) use has become more common, gaining increasing acceptance as a safer alternative to tobacco smoking. However, the 2019 outbreak of Ecig and Vaping-Associated Lung Injury (EVALI) alerted the community to the potential for incorporation of deleterious ingredients such as vitamin E acetate into products without adequate safety testing. Understanding Ecig induced molecular changes in the lung and systemically can provide a path to safety assessment and protect consumers from unsafe formulations. While vitamin E acetate has been largely removed from commercial and illicit products, many Ecig products contain additives that remain largely uncharacterized. In this study, we determined the lung-specific effects as well as systemic immune effects in response to exposure to a common Ecig base, propylene glycol and vegetable glycerin (PGVG), with and without a 1% addition of phytol, a diterpene alcohol that has been found in commercial products. We exposed animals to PGVG with and without phytol and assessed metabolite, lipid, and transcriptional markers in the lung. We found both lung-specific as well as systemic effects in immune parameters, metabolites, and lipids. Phytol drove modest changes in lung function and increased splenic CD4 T cell populations. We also conducted multi-omic data integration to better understand early complex pulmonary responses, highlighting a central enhancement of acetylcholine responses and downregulation of palmitic acid connected with conventional flow cytometric assessments of lung, systemic inflammation, and pulmonary function. Our results demonstrate that Ecig exposure not only leads to changes in pulmonary function but also affects systemic immune and metabolic parameters.
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Affiliation(s)
- David P Scieszka
- Department of Pharmaceutical Sciences, University of New Mexico School of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Devon Garland
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, MSC 08 4660, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Russell Hunter
- Department of Pharmaceutical Sciences, University of New Mexico School of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Guy Herbert
- Department of Pharmaceutical Sciences, University of New Mexico School of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Selita Lucas
- Department of Pharmaceutical Sciences, University of New Mexico School of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Yan Jin
- Center for Translational Science, Florida International University, Port St. Lucie, FL, USA
| | - Haiwei Gu
- Center for Translational Science, Florida International University, Port St. Lucie, FL, USA
| | - Matthew J Campen
- Department of Pharmaceutical Sciences, University of New Mexico School of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Judy L Cannon
- Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, MSC 08 4660, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
- Autophagy, Inflammation, and Metabolism Center of Biomedical Research Excellence, University of New Mexico School of Medicine, Albuquerque, NM, USA.
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3
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Zhou Y, Zhao X, Hu W, Ruan F, He C, Huang J, Zuo Z. Acute and subacute oral toxicity of propylene glycol enantiomers in mice and the underlying nephrotoxic mechanism. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2021; 290:118050. [PMID: 34461418 DOI: 10.1016/j.envpol.2021.118050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/22/2021] [Accepted: 08/23/2021] [Indexed: 06/13/2023]
Abstract
Propylene glycol (PG; 1,2-propanediol) has been commonly used as a food additive and vehicle in pharmaceutical preparations. PG can form rectus (R-) enantiomers and sinister (S-) enantiomers. Herein, Kunming mice were used as the animal model to evaluate the acute and subacute oral toxicity of R-PG, S-PG and RS-PG (1:1 racemic mixture of R-PG and S-PG). The median lethal doses of R-PG, S-PG and RS-PG administered by oral gavage to mice were 22.81 g/kg, 26.62 g/kg and 24.92 g/kg, respectively. In the 28-day oral subacute toxicity study, the body weight, organ weights, serum biochemical, and renal histology were examined. There was no difference in subacute toxicity among R-PG, S-PG and RS-PG. The administration of 1 and 5 g/kg/day PG for 28 days caused nephrotoxicity. The kidney somatic index and levels of blood urea nitrogen exhibited a significant increase. Moreover, the activities of superoxide dismutase, catalase, and glutathione peroxidase significantly decreased after the treatment with PG. The levels of malondialdehyde, tumor necrosis factor α, interleukin 1β, and interleukin 6 significantly increased in the kidney. The results show that the nephrotoxic effects of PG are induced by oxidative stress, and the activation of the inflammatory response is mediated by the NF-κB signaling pathway. Together, these findings provide information on R-PG, S-PG and RS-PG treatments for the risk assessment of toxicity and effects on human health.
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Affiliation(s)
- Yixi Zhou
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, The Fifth Hospital of Xiamen, Xiang'an Branch of the First Affiliated Hospital, Xiamen University, Xiamen, Fujian, 361102, China
| | - Xijing Zhao
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, The Fifth Hospital of Xiamen, Xiang'an Branch of the First Affiliated Hospital, Xiamen University, Xiamen, Fujian, 361102, China
| | - Weiping Hu
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, The Fifth Hospital of Xiamen, Xiang'an Branch of the First Affiliated Hospital, Xiamen University, Xiamen, Fujian, 361102, China
| | - Fengkai Ruan
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, The Fifth Hospital of Xiamen, Xiang'an Branch of the First Affiliated Hospital, Xiamen University, Xiamen, Fujian, 361102, China
| | - Chengyong He
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, The Fifth Hospital of Xiamen, Xiang'an Branch of the First Affiliated Hospital, Xiamen University, Xiamen, Fujian, 361102, China
| | - Jiyi Huang
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, The Fifth Hospital of Xiamen, Xiang'an Branch of the First Affiliated Hospital, Xiamen University, Xiamen, Fujian, 361102, China
| | - Zhenghong Zuo
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, The Fifth Hospital of Xiamen, Xiang'an Branch of the First Affiliated Hospital, Xiamen University, Xiamen, Fujian, 361102, China.
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4
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Woodall M, Jacob J, Kalsi KK, Schroeder V, Davis E, Kenyon B, Khan I, Garnett JP, Tarran R, Baines DL. E-cigarette constituents propylene glycol and vegetable glycerin decrease glucose uptake and its metabolism in airway epithelial cells in vitro. Am J Physiol Lung Cell Mol Physiol 2020; 319:L957-L967. [PMID: 32996783 PMCID: PMC7792687 DOI: 10.1152/ajplung.00123.2020] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 02/07/2023] Open
Abstract
Electronic nicotine delivery systems, or e-cigarettes, utilize a liquid solution that normally contains propylene glycol (PG) and vegetable glycerin (VG) to generate vapor and act as a carrier for nicotine and flavorings. Evidence indicated these "carriers" reduced growth and survival of epithelial cells including those of the airway. We hypothesized that 3% PG or PG mixed with VG (3% PG/VG, 55:45) inhibited glucose uptake in human airway epithelial cells as a first step to reducing airway cell survival. Exposure of H441 or human bronchiolar epithelial cells (HBECs) to PG and PG/VG (30-60 min) inhibited glucose uptake and mitochondrial ATP synthesis. PG/VG inhibited glycolysis. PG/VG and mannitol reduced cell volume and height of air-liquid interface cultures. Mannitol, but not PG/VG, increased phosphorylation of p38 MAPK. PG/VG reduced transepithelial electrical resistance, which was associated with increased transepithelial solute permeability. PG/VG decreased fluorescence recovery after photobleaching of green fluorescent protein-linked glucose transporters GLUT1 and GLUT10, indicating that glucose transport function was compromised. Puffing PG/VG vapor onto the apical surface of primary HBECs for 10 min to mimic the effect of e-cigarette smoking also reduced glucose transport. In conclusion, short-term exposure to PG/VG, key components of e-cigarettes, decreased glucose transport and metabolism in airway cells. We propose that this was a result of PG/VG reduced cell volume and membrane fluidity, with further consequences on epithelial barrier function. Taking these results together, we suggest these factors contribute to reduced defensive properties of the epithelium. We propose that repeated/chronic exposure to these agents are likely to contribute to airway damage in e-cigarette users.
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Affiliation(s)
- M. Woodall
- Institute for Infection and Immunity, St George’s, University of London, Tooting, London, United Kingdom
| | - J. Jacob
- Institute for Infection and Immunity, St George’s, University of London, Tooting, London, United Kingdom
| | - K. K. Kalsi
- Institute for Infection and Immunity, St George’s, University of London, Tooting, London, United Kingdom
| | - V. Schroeder
- Immunology and Respiratory Diseases Research, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - E. Davis
- Marsico Lung Institute and Department of Cell Biology and Physiology, University of North Carolina, Chapel Hill, North Carolina
| | - B. Kenyon
- Marsico Lung Institute and Department of Cell Biology and Physiology, University of North Carolina, Chapel Hill, North Carolina
| | - I. Khan
- Institute for Infection and Immunity, St George’s, University of London, Tooting, London, United Kingdom
| | - J. P. Garnett
- Immunology and Respiratory Diseases Research, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
| | - R. Tarran
- Marsico Lung Institute and Department of Cell Biology and Physiology, University of North Carolina, Chapel Hill, North Carolina
| | - D. L. Baines
- Institute for Infection and Immunity, St George’s, University of London, Tooting, London, United Kingdom
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5
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Smedley LW, Rios D, Barthol CA, Garvin RE. Iatrogenic Propylene Glycol Intoxication Due to High-Dose Pentobarbital for Refractory Intracranial Hypertension: A Case Report. J Pharm Pract 2019; 33:895-898. [PMID: 31238770 DOI: 10.1177/0897190019854575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Propylene glycol is a rarely reported toxicity from high-dose administration of certain intravenous drugs, including lorazepam and pentobarbital. We present a case of iatrogenic propylene glycol toxicity secondary to a high-dose pentobarbital infusion for the treatment of refractory intracranial hypertension due to cerebral venous sinus thrombosis. The patient developed metabolic acidosis and acute kidney failure secondary to propylene glycol toxicity. After initiation of continuous renal replacement therapy, the patient's acute renal failure and lactic acidosis resolved. Using the Naranjo scale, this case received a score of 5, defining it as a "probable" adverse drug event. In patients who develop lactic acidosis and acute renal failure after initiation of high-dose pentobarbital, propylene glycol toxicity should be higher up in the differential diagnosis. Monitoring the serum osmolality while on pentobarbital could help provide valuable information to prevent iatrogenic propylene glycol toxicity.
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Affiliation(s)
- Lucas W Smedley
- Department of Pharmacotherapy and Pharmacy Services, University Health System, San Antonio, TX, USA.,Pharmacotherapy Research and Education Center, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, San Antonio, TX, USA
| | - Denise Rios
- Department of Neurosurgery, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Colleen A Barthol
- Department of Pharmacotherapy and Pharmacy Services, University Health System, San Antonio, TX, USA.,Pharmacotherapy Research and Education Center, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Division of Pharmacotherapy, College of Pharmacy, University of Texas at Austin, San Antonio, TX, USA
| | - Rachel E Garvin
- Department of Neurosurgery, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Department of Emergency Medicine, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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6
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Isildar B, Ozkan S, Oncul M, Baslar Z, Kaleli S, Tasyurekli M, Koyuturk M. Comparison of different cryopreservation protocols for human umbilical cord tissue as source of mesenchymal stem cells. Acta Histochem 2019; 121:361-367. [PMID: 30837094 DOI: 10.1016/j.acthis.2019.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 12/31/2022]
Abstract
The main purpose of this study is to establish an effective cryopreservation protocol for the umbilical cord tissue as a source of mesenchymal stem cells (MSCs). In this context, it was aimed to use a cryoprotectant that could be an alternative to dimethyl sulfoxide (DMSO) which is commonly used despite the toxic side effects. Therefore, two different cryopreservation solutions were prepared using 10% DMSO and 10% 1,2 propanediol (PrOH). The fresh tissue group that was not performed cryopreservation was used as the control group. Following the cryopreservation step, MSCs were isolated from all groups and compared with each other to assess the efficiency of the cryopreservation solutions. The comparison was performed in terms of followings: morphology, immunophenotypes, growth kinetics, differentiation, and ultrastructural features. Based on the results, there were no significant morphological and immunophenotypic differences between the MSCs isolated from cryopreserved tissue groups and the MSCs isolated from the fresh tissue group. According to the growth kinetic analysis, the cells isolated from the PrOH group had a lower proliferation rate than the cells isolated from the fresh tissue. However, there was no significant difference between the cryopreserved groups in this respect. Osteogenic and adipogenic differentiation was observed in all groups. Upon comparison of the cryopreserved groups, PrOH group was discovered to hold a minor superiority in terms of these modes of differentiation. These results suggest that PrOH, which is considered as a cryoprotectant with low toxicity, could be used as a preferred cryoprotectant instead of DMSO concerning the process of cryopreservation of the umbilical cord.
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Affiliation(s)
- Basak Isildar
- Department of Histology and Embryology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey.
| | - Serbay Ozkan
- Department of Histology and Embryology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mahmut Oncul
- Department of Gynecology and Obstetrics, Cerrahpasa Medical Faculty, Istanbul University- Cerrahpasa, Istanbul, Turkey
| | - Zafer Baslar
- Division of Hematology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Semih Kaleli
- Department of Gynecology and Obstetrics, Cerrahpasa Medical Faculty, Istanbul University- Cerrahpasa, Istanbul, Turkey
| | - Mustafa Tasyurekli
- Department of Histology and Embryology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Meral Koyuturk
- Department of Histology and Embryology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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7
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Acute Renal Failure Secondary to Inadvertent Propylene Glycol Overdose with Single-Day High-Dose Vitamin D (Stosstherapy). Case Rep Endocrinol 2019; 2019:1482727. [PMID: 30805225 PMCID: PMC6360572 DOI: 10.1155/2019/1482727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 12/11/2018] [Indexed: 11/17/2022] Open
Abstract
Globally, there has been increasing attention paid to vitamin D deficiency and its treatment. Vitamin D stosstherapy with high-dose ergocalciferol in a single day is reemerging as a potential treatment option. We present an as yet unreported complication of acute renal injury due to propylene glycol toxicity in a 7-month infant treated with vitamin D stosstherapy. The product label for the vitamin D used for this patient states it is dissolved in propylene glycol (PG), but the amount is not listed on this or other US ergocalciferol liquid products that contain PG. Caution should be used when considering vitamin D stosstherapy with liquid ergocalciferol products available in the United States.
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8
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Carroll TB, Peppard WJ, Herrmann DJ, Javorsky BR, Wang TS, Patel H, Zarnecki K, Findling JW. Continuous Etomidate Infusion for the Management of Severe Cushing Syndrome: Validation of a Standard Protocol. J Endocr Soc 2018; 3:1-12. [PMID: 30560224 PMCID: PMC6291660 DOI: 10.1210/js.2018-00269] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/23/2018] [Indexed: 12/13/2022] Open
Abstract
Objective Demonstrate the safety and efficacy of a standardized intravenous etomidate infusion protocol in normalizing cortisol levels in patients with severe and life-threatening hypercortisolism. Methods A retrospective case series of seven patients representing nine episodes of severe hypercortisolism at two large academic medical centers was conducted. Patients were included in this series if they received an etomidate infusion for the treatment of severe and life-threatening hypercortisolism. The etomidate infusion was administered via a newly developed protocol designed to safely reduce cortisol levels until more long-term medical or definitive surgical therapy could be instituted. Results Seven patients representing nine episodes received etomidate treatment. In eight of nine episodes of therapy, rapid control of hypercortisolemia was achieved, generally defined as a serum cortisol level of 10 to 20 µg/dL. Patients with a median baseline cortisol of 105 µg/dL (range, 32 to 245 µg/dL) achieved a median nadir serum cortisol of 15.8 µg/dL (range, 6.9 to 27 µg/dL) after a median of 38 hours (range, 26 to 134 hours). Conclusions A standardized continuous intravenous etomidate infusion protocol is a safe and effective means of achieving a serum cortisol level of 10 to 20 µg/dL in patients with severe hypercortisolemia.
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Affiliation(s)
- Ty B Carroll
- Endocrine Center and Clinics, Froedtert Hospital and the Medical College of Wisconsin, Menomonee Falls, Wisconsin
| | - William J Peppard
- Department of Pharmacy, Froedtert Hospital, Milwaukee, Wisconsin.,Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David J Herrmann
- Department of Pharmacy, Froedtert Hospital, Milwaukee, Wisconsin
| | - Bradley R Javorsky
- Endocrine Center and Clinics, Froedtert Hospital and the Medical College of Wisconsin, Menomonee Falls, Wisconsin
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hina Patel
- Department of Pharmacy, NorthShore University Health System, Evanston, Illinois
| | - Katarzyna Zarnecki
- Division of Endocrinology, University of Chicago, NorthShore University Health System, Skokie, Illinois
| | - James W Findling
- Endocrine Center and Clinics, Froedtert Hospital and the Medical College of Wisconsin, Menomonee Falls, Wisconsin
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9
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Golden TR, Solnicky V, Wadeea R, Ghazala S. Pentobarbital-induced lactic acidosis following status epilepticus barbiturate coma. BMJ Case Rep 2018; 2018:bcr-2017-223482. [PMID: 29472424 DOI: 10.1136/bcr-2017-223482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a rare case of pentobarbital infusion causing propylene glycol-induced lactic acidosis, during refractory status epilepticus treatment in a 66-year-old man without seizure history.
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Affiliation(s)
| | | | - Rita Wadeea
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Sehem Ghazala
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
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10
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Propylene Glycol Toxicity in Adolescent with Refractory Myoclonic Status Epilepticus. Case Rep Pediatr 2017; 2017:2979486. [PMID: 28331645 PMCID: PMC5346383 DOI: 10.1155/2017/2979486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/12/2017] [Indexed: 11/28/2022] Open
Abstract
Propylene glycol (PG) is a solvent commonly used in medications that, while benign at low doses, may cause toxicity in adults and children at high doses. We describe a case and the physiologic sequelae of propylene glycol toxicity manifested in a critically ill adolescent male with refractory myoclonic status epilepticus aggressively treated with multiple PG-containing medications (lorazepam, phenobarbital, and pentobarbital)—all within accepted dosing guidelines and a total daily PG exposure previously recognized to be safe. Hemodynamic measurements by bedside echocardiography during clinical toxicity are also reported. Clinicians should have a high index of suspicion for propylene glycol toxicity in patients treated with PG-containing medications even when the total PG exposure is lower than currently accepted limits.
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11
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Lavoisier J, Boulle-Geronimi C, Mégarbane B. Fatality associated with propylene glycol poisoning in a cirrhotic patient. Clin Toxicol (Phila) 2016; 54:462-3. [DOI: 10.3109/15563650.2016.1155126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Johann Lavoisier
- Service De Réanimation Polyvalente, Centre Hospitalier De Douai, Douai, France
| | | | - Bruno Mégarbane
- Réanimation Médicale Et Toxicologique, Hôpital Lariboisière;, Université Paris-Diderot, Paris, France
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12
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Bulathsinghala M, Keefer K, Van de Louw A. Trimethoprim/Sulfamethoxazole-Induced Severe Lactic Acidosis: A Case Report and Review of the Literature. Medicine (Baltimore) 2016; 95:e3478. [PMID: 27124045 PMCID: PMC4998708 DOI: 10.1097/md.0000000000003478] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Propylene glycol (PG) is used as a solvent in numerous medications, including trimethoprim/sulfamethoxazole (TMP/SMX) and lorazepam, and is metabolized in the liver to lactic acid. Cases of lactic acidosis related to PG toxicity have been described and always involved large doses of benzodiazepines and PG. We present the first case of severe lactic acidosis after a 3-day course of TMP/SMX alone, involving allegedly safe amounts of PG.A 31-year-old female with neurofibromatosis and pilocytic astrocytoma, receiving temozolomide and steroids, was admitted to the intensive care unit for pneumonia and acute respiratory failure requiring intubation. Her initial hemodynamic and acid-base statuses were normal. She was treated with intravenous TMP/SMX for possible Pneumocystis jirovecii pneumonia and was successfully extubated on day 2. On day 3, she developed tachypnea and arterial blood gas analysis revealed a severe metabolic acidosis (pH 7.2, PCO2 19 mm Hg, bicarbonates 8 mEq/L) with anion gap of 25 mEq/L and lactate of 12.1 mmol/L. TMP/SMX was discontinued and the lactate decreased to 2.9 mmol/L within 24 hours while her plasma bicarbonates normalized, without additional intervention. The patient never developed hypotension or severe hypoxia, and her renal and liver functions were normal. No other cause for lactic acidosis was identified and it resolved after TMP/SMX cessation alone, suggesting PG toxicity.Although PG-related lactic acidosis is well recognized after large doses of lorazepam, clinicians should bear in mind that TMP/SMX contains PG as well and should suspect PG toxicity in patients developing unexplained metabolic acidosis while receiving TMP/SMX.
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Affiliation(s)
- Marie Bulathsinghala
- From the Division of Pulmonary and Critical Care Medicine (MB, AVDL) and Department of Pharmacy, Penn State University College of Medicine and Milton S Hershey Medical Center (KK), Hershey, PA
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13
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Abstract
Metabolic acidosis could emerge from diseases disrupting acid-base equilibrium or from drugs that induce similar derangements. Occurrences are usually accompanied by comorbid conditions of drug-induced metabolic acidosis, and clinical outcomes may range from mild to fatal. It is imperative that clinicians not only are fully aware of the list of drugs that may lead to metabolic acidosis but also understand the underlying pathogenic mechanisms. In this review, we categorized drug-induced metabolic acidosis in terms of pathophysiological mechanisms, as well as individual drugs’ characteristics.
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Affiliation(s)
- Amy Quynh Trang Pham
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Departments of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Baylor Family Medicine Residency at Garland, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
| | - Li Hao Richie Xu
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
| | - Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Departments of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Department of Physiology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
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Pivonello R, De Leo M, Cozzolino A, Colao A. The Treatment of Cushing's Disease. Endocr Rev 2015; 36:385-486. [PMID: 26067718 PMCID: PMC4523083 DOI: 10.1210/er.2013-1048] [Citation(s) in RCA: 288] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/13/2015] [Indexed: 12/23/2022]
Abstract
Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Monica De Leo
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Alessia Cozzolino
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
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Abstract
Propylene glycol (PG) is a commonly used solvent for oral, intravenous, and topical pharmaceutical agents. Although PG is generally considered safe, when used in high doses or for prolonged periods, PG toxicity can occur. Reported adverse effects from PG include central nervous system (CNS) toxicity, hyperosmolarity, hemolysis, cardiac arrhythmia, seizures, agitation, and lactic acidosis. Patients at risk for toxicity include infants, those with renal or hepatic insuficiency, epilepsy, and burn patients receiving extensive dermal applications of PG containing products. Laboratory monitoring of PG levels, osmolarity, lactate, pyruvate, bicarbonate, creatinine, and anion gap can assist practitioners in making the diagnosis of PG toxicity. Numerous studies and case reports have been published on PG toxicity in adults. However, very few have been reported in pediatric patient populations. A review of the literature is presented.
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Affiliation(s)
- Terri Y Lim
- Departments of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Robert L Poole
- Departments of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Natalie M Pageler
- Division of Critical Care Medicine, Department of Pediatrics, Stanford University Medical School, Stanford, California ; Clinical Informatics, Lucile Packard Children's Hospital Stanford, Palo Alto, California
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Abstract
Propylene glycol toxicity presenting as high anion gap metabolic acidosis and osmolar gap has been extensively reported in literature, and most of them are secondary to intravenous lorazepam infusion. However, propylene glycol is used as a solvent in a number of medications that are frequently utilized in critical care setting, and hence one should be aware that the toxicity is possible from a variety of medication. Phenobarbital and phenytoin are one of those, and we hereby report a novel case of propylene glycol toxicity secondary to phenobarbital and phenytoin infusion in a patient with refractory status epilepticus. Furthermore, our patient had end-stage renal disease, which we think could have been an important precipitating factor for the toxicity. Because most of the symptoms from propylene glycol toxicity can mimic sepsis-which is very common in critical care unit patients-this life threatening scenario could be easily missed. Regular monitoring of osmolar gap is an easily available intervention in the at risk patients.
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Claus MA, Jandrey KE, Poppenga RH. Propylene glycol intoxication in a dog. J Vet Emerg Crit Care (San Antonio) 2011; 21:679-83. [DOI: 10.1111/j.1476-4431.2011.00688.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Melissa A. Claus
- Veterinary Medical Teaching Hospital; University of California Davis; Davis; CA; 95616
| | - Karl E. Jandrey
- The Department of Surgical and Radiological Sciences; University of California Davis; Davis; CA; 95616
| | - Robert H. Poppenga
- Department of Molecular Biosciences; California Animal Health and Food Safety Laboratory; University of California Davis; Davis; CA; 95616
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Sampathkumar K, Yesudas S. Hair dye poisoning and the developing world. J Emerg Trauma Shock 2011; 2:129-31. [PMID: 19561974 PMCID: PMC2700586 DOI: 10.4103/0974-2700.50749] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Accepted: 09/16/2008] [Indexed: 12/05/2022] Open
Abstract
Hair dye poisoning has been emerging as one of the important causes of intentional self harm in the developing world. Hair dyes contain paraphenylene-diamine and a host of other chemicals that can cause rhabdomyolysis, laryngeal edema, severe metabolic acidosis and acute renal failure. Intervention at the right time has been shown to improve the outcome. In this article, we review the various manifestations, clinical features and treatment modalities for hair dye poisoning.
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Affiliation(s)
- Krishnaswamy Sampathkumar
- Department of Nephrology, Meenakshi Mission Hospital and Research Centre, Lake Area, Melur Road, Madurai, Tamil Nadu - 625 107, India
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19
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Zhao C, Wang L, Zu Y, Li C, Liu S, Yang L, Zhao X, Zu B. Micronization of Ginkgo biloba extract using supercritical antisolvent process. POWDER TECHNOL 2011. [DOI: 10.1016/j.powtec.2011.02.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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20
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Abstract
Double gap metabolic acidosis occurs in the setting of unmeasured active osmoles in the serum (osmolal gap) and anion gap (AG) metabolic acidosis. We describe a 67-year-old woman with acute respiratory failure on mechanical ventilator from pneumonia and anuric acute on chronic renal failure (urea nitrogen 21.4 mmol/L, creatinine 530.4 μmol/L) requiring haemodialysis (HD). On hospital day 5, she was found to have progressive metabolic acidosis (serum pH 7.16, PCO2 4.38 kPa, HCO3− 12.1 mmol/L and AG 21 mmol/L). There was no evidence of hypoxaemia, hypoperfusion or haemodynamic instability. Normal serum ketone and l-lactate but high serum osmolal gap (89.4 mmol/kg) was detected. A search for toxic alcohols revealed a high serum propylene glycol (PG 32.9 mmol/L), a stabilizing solvent for intravenous formulations of lorazepam, which was being used as sedation for mechanical ventilation. Unexpectedly, serum l- and d-lactate as metabolites of PG were not elevated. Although extended HD for eight hours completely removed serum PG and the osmolal gap, the predialysis high AG metabolic acidosis persisted, potentially related to hypercatabolism and anuric renal failure. PG should be in the differential diagnosis of the disorders with high osmolar gap and may not always be associated with l- or d-lactic acidosis.
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Affiliation(s)
- Ming-Tso Yan
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tom Chau
- Department of Medicine, Providence St Vincent Medical Center, Portland, OR, USA
| | - Chih-Jen Cheng
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Hayner CE, Wuestefeld NL, Bolton PJ. Phenobarbital treatment in a patient with resistant alcohol withdrawal syndrome. Pharmacotherapy 2009; 29:875-8. [PMID: 19558262 DOI: 10.1592/phco.29.7.875] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Alcohol withdrawal syndrome (AWS) is a major cause of morbidity and mortality in the acute care setting. We describe a 28-year-old man who was brought to the emergency department with a new-onset seizure and clinical signs and symptoms consistent with advanced delirium tremens. A symptom-triggered intensive care unit treatment protocol consisting of a benzodiazepine and antiadrenergic agents was started. The manifestations of delirium tremens persisted with titration of a lorazepam infusion in excess of 40 mg/hour. Intravenous phenobarbital was administered in escalating doses of 65 mg followed by 130 mg 15 minutes later, resulting in control of severe agitation in the face of benzodiazepine resistance. Subsequent scheduled phenobarbital administration allowed for a successful and orderly weaning of the continuous benzodiazepine infusion and adjunctive agents used in AWS management. With continued clearing of consciousness, the patient was successfully discharged. The administration of phenobarbital in this patient allowed improved symptom control, minimized the potential for propylene glycol toxicity, was not associated with respiratory depression, and facilitated successful weaning of benzodiazepines. Barbiturates offer a mechanism of action that is different from that of benzodiazepines. Although the cornerstone of treatment for AWS remains benzodiazepines, this case highlights the potential utility of phenobarbital in patients with resistant AWS.
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Affiliation(s)
- Christopher E Hayner
- Department of Internal Medicine, Pulmonary and Critical Care Division, Good Samaritan Hospital, Cincinnati, Ohio, USA.
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Hyperosmolar, increased-anion-gap metabolic acidosis and hyperglycemia after etomidate infusion. J Clin Anesth 2008; 20:290-3. [PMID: 18617128 DOI: 10.1016/j.jclinane.2007.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2006] [Revised: 11/26/2007] [Accepted: 12/05/2007] [Indexed: 11/23/2022]
Abstract
Hyperosmolar increased-anion-gap metabolic acidosis without hyperglycemia has been reported after infusions of etomidate and other medications containing propylene glycol. We report a case of this biochemical abnormality with severe hyperglycemia. Cessation of the etomidate infusion along with other supportive measures resulted in prompt resolution of the metabolic acidosis and hyperglycemia.
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Nelsen JL, Haas CE, Habtemariam B, Kaufman DC, Partridge A, Welle S, Forrest A. A prospective evaluation of propylene glycol clearance and accumulation during continuous-infusion lorazepam in critically ill patients. J Intensive Care Med 2008; 23:184-94. [PMID: 18543419 DOI: 10.1177/0885066608315808] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Propylene glycol is a commonly used diluent in several pharmaceutical preparations, including the sedative lorazepam. Fifty critically ill patients receiving continuous-infusion lorazepam for a minimum of 36 hours were prospectively evaluated to determine the extent of propylene glycol accumulation over time, characterize propylene glycol clearance in the presence of critical illness, and develop a pharmacokinetic model that would predict clearance based on patient-specific clinical, laboratory, and demographic factors. In this cohort, the median lorazepam infusion rate was 2.1 mg/h (0.5-18). Propylene glycol concentration correlated poorly with osmolality, osmol gap, and lactate. In all, 8 patients (16%) had significant propylene glycol accumulation (>25mg/dL). When propylene glycol concentrations were >25 mg/dL, the median lorazepam infusion rate before sample collection was higher, 6.4 (1.9-11.3) versus 2.0 (0.5-7.4) mg/h (P =.0003). A linear first-order model with interoccasion variability on clearance adjusted for total body weight and Acute Physiology and Chronic Health Evaluation II score predicted propylene glycol concentration.
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Affiliation(s)
- Jamie L Nelsen
- Department of Emergency Medicine, State University of New York, Upstate Medical University, Syracuse, NY 13210, USA.
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Miller MA, Forni A, Yogaratnam D. Propylene glycol-induced lactic acidosis in a patient receiving continuous infusion pentobarbital. Ann Pharmacother 2008; 42:1502-6. [PMID: 18698010 DOI: 10.1345/aph.1l186] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report a case of probable propylene glycol (PG) toxicity in a patient receiving continuous infusion of pentobarbital for refractory status epilepticus. CASE SUMMARY A 59-year-old woman with a declining mental status was admitted to the intensive care unit for management of status epilepticus. After failing to achieve the therapeutic endpoint of electroencephalogram burst suppression with a continuous infusion of propofol, the sedative regimen was changed to continuous infusion of pentobarbital. The patient received a loading dose of 450 mg (5 mg/kg), and the maintenance infusion was titrated to a dose of 10 mg/kg/h to achieve burst suppression. Twelve hours after the pentobarbital infusion was started, the patient developed an anion gap metabolic acidosis, elevated serum lactate level, hyperosmolality, and increased osmolal gap. The pentobarbital infusion was discontinued, and the patient's acidosis and hyperosmolality resolved. DISCUSSION Pentobarbital contains 40% v/v of PG, which was thought to be a potential source of the patient's metabolic derangements. Reports of toxicity with drugs containing PG, particularly intravenous lorazepam, have been well described in the literature. What we describe, however, is one of few reports involving intravenous pentobarbital. The Naranjo probability scale supports a probable drug-related adverse event in our patient. CONCLUSIONS PG toxicity is a potential complication associated with intravenous pentobarbital. Practitioners should be aware of the PG content of pentobarbital and should be familiar with the signs and symptoms associated with PG toxicity.
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Affiliation(s)
- Melissa A Miller
- Critical Care, Department of Pharmacy, University of Massachusetts Memorial Medical Center, Worcester, MA 01655, USA.
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Yahwak JA, Riker RR, Fraser GL, Subak-Sharpe S. Determination of a Lorazepam Dose Threshold for Using the Osmol Gap to Monitor for Propylene Glycol Toxicity. Pharmacotherapy 2008; 28:984-91. [DOI: 10.1592/phco.28.8.984] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Dexmedetomidine is being used off-label as an adjunctive agent for sedation and analgesia in pediatric patients in the critical care unit and for sedation during non-invasive procedures in radiology. It also has a potential role as part of anesthesia care to prevent emergence delirium and postanesthesia shivering. Dexmedetomidine is currently approved by the US FDA for sedation only in adults undergoing mechanical ventilation for <24 hours. Pediatric experiences in the literature are in the form of small studies and case reports. In patients sedated for mechanical ventilation and/or opioid/benzodiazepine withdrawal, the loading dose ranged from 0.5 to 1 microg/kg and was usually administered over 10 minutes, although not all patients received loading doses. This patient group also received a continuous infusion at rates ranging from 0.2 to 2 microg/kg/h, with higher rates used in burn patients and those with withdrawal following > or =24 hours of opioid/benzodiazepine infusion. The dexmedetomidine dosage used for anesthesia and sedation during non-invasive procedures, such as radiologic studies, ranged from a loading dose of 1-2 microg/kg followed by a continuous infusion at 0.5-1.14 microg/kg/h, with most patients spontaneously breathing. For invasive procedures, such as awake craniotomy or cardiac catheterization, dosage ranged from a loading dose of 0.15 to 1 microg/kg followed by a continuous infusion at 0.1-2 microg/kg/h. Adverse hemodynamic and respiratory effects were minimal; the agent was well tolerated in most patients. The efficacy of dexmedetomidine varied depending on the clinical situation: efficacy was greatest during non-invasive procedures, such as magnetic resonance imaging (MRI), and lowest during invasive procedures, such as cardiac catheterization. Dexmedetomidine may be useful in pediatric patients for sedation in a variety of clinical situations. The literature suggests potential use of dexmedetomidine as an adjunctive agent to other sedatives during mechanical ventilation and opioid/benzodiazepine withdrawal. In addition, because of its minimal respiratory effects, dexmedetomidine has also been used as a single agent for sedation during non-invasive procedures such as MRI. However, additional studies in pediatric patients are warranted to further evaluate its safety and efficacy in all age ranges.
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Affiliation(s)
- Hanna Phan
- College of Pharmacy, The Ohio State University, Columbus, Ohio, USA
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Zar T, Yusufzai I, Sullivan A, Graeber C. Acute kidney injury, hyperosmolality and metabolic acidosis associated with lorazepam. ACTA ACUST UNITED AC 2007; 3:515-20. [PMID: 17717564 DOI: 10.1038/ncpneph0573] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Accepted: 06/29/2007] [Indexed: 11/09/2022]
Abstract
BACKGROUND A 54-year-old male with a history of multiple admissions for alcohol intoxication was admitted to hospital with right flank pain. He received a high-dose lorazepam infusion for alcohol withdrawal during hospitalization and developed severe hyperosmolality, high anion gap metabolic acidosis, and acute kidney injury on his eighth day of hospitalization. INVESTIGATIONS Serum chemistries, arterial blood gas analysis, and measurement of serum propylene glycol, ethylene glycol and methanol levels. DIAGNOSIS Propylene glycol toxicity. MANAGEMENT Discontinuation of lorazepam infusion, administration of fomepizole, hemodialysis for five consecutive days, hemodynamic support, and follow-up of serum osmolality as a measure of propylene glycol decay.
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Affiliation(s)
- Tausif Zar
- Division of Nephrology, Department of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA.
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30
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Sampathkumar K, Sooraj YS, Ajeshkumar RP, Mahaldar AR, Muthiah R. Rhabdomyolysis due to hair dye poisoning: An emerging threat. Indian J Crit Care Med 2007. [DOI: 10.4103/0972-5229.37717] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Barnes BJ, Gerst C, Smith JR, Terrell AR, Mullins ME. Osmol Gap as a Surrogate Marker for Serum Propylene Glycol Concentrations in Patients Receiving Lorazepam for Sedation. Pharmacotherapy 2006; 26:23-33. [PMID: 16422667 DOI: 10.1592/phco.2006.26.1.23] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To correlate serum propylene glycol concentration with osmol gap, serum lactate concentration, and amount of propylene glycol administered to mechanically ventilated patients receiving continuous infusions of lorazepam (80% propylene glycol by weight), and to characterize the prevalence of hyperosmolality and range of serum propylene glycol concentrations in this patient population. DESIGN Prospective, controlled, observational study. SETTING Adult surgical and cardiothoracic intensive care units (ICUs) of a 1200-bed, urban, tertiary care, teaching hospital. PATIENTS Sixty-four consecutively enrolled intensive care patients requiring mechanical ventilation and pharmacologic sedation. INTERVENTION Thirteen patients received continuous infusions of high-dose lorazepam (> or = 6 mg/hr) for a minimum of 36 hours, and 26 received continuous infusions of low-dose lorazepam (2-5.99 mg/hr) for 36 hours. Twenty-five control patients received sedatives that did not contain propylene glycol. MEASUREMENTS AND MAIN RESULTS Serum propylene glycol and lactate concentrations, osmolality, and basic metabolic profiles were obtained 72-108 hours after ICU admission. Clinical data, drug administration, and severity of illness scores were recorded. Osmol gap and the amount of propylene glycol administered before serum sampling predicted propylene glycol concentrations (r(2)=0.692, p<0.05). Osmol gap alone also predicted serum propylene glycol concentrations (r(2)=0.532, p<0.05). Serum lactate concentrations did not correlate with serum propylene glycol concentrations. Unlike the low-dose and control patients, eight (62%) of 13 high-dose patients had osmol gaps above 10. All 13 high-dose patients had serum propylene glycol concentrations previously associated with toxicity. CONCLUSION Osmol gap can be used as a surrogate marker for serum propylene glycol concentration. In critically ill patients receiving lorazepam for sedation, an osmol gap above 10 was associated with concentrations previously reported to cause toxicity.
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Affiliation(s)
- Brian J Barnes
- Department of Pharmacy, Barnes-Jewish Hospital, Washington University, School of Medicine, St. Louis, Missouri, USA.
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P66 - Insuffisance rénale aiguë suite à l’application de sulfadiazine argentique. Ann Dermatol Venereol 2005. [DOI: 10.1016/s0151-9638(05)79795-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Neale BW, Mesler EL, Young M, Rebuck JA, Weise WJ. Propylene Glycol–Induced Lactic Acidosis in a Patient with Normal Renal Function: A Proposed Mechanism and Monitoring Recommendations. Ann Pharmacother 2005; 39:1732-6. [PMID: 16159998 DOI: 10.1345/aph.1g083] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE:To report a case of severe propylene glycol–induced lactic acidosis not attributable to renal dysfunction that was secondary to administration of high-dose intravenous lorazepam.CASE SUMMARY:A 24-year-old female with community-acquired pneumonia presented with severe acute respiratory distress syndrome. To maintain adequate sedation and ventilation and reduce airway pressure, several relaxation strategies were used including high-dose intravenous lorazepam, fentanyl, and cisatracurium. After 18 days of high-dose continuous infusion of lorazepam (maximum dose 50 mg/h), the patient developed severe lactic acidosis secondary to propylene glycol toxicity, the main diluent of lorazepam. The acidosis temporarily resolved with bicarbonate administration and discontinuation of lorazepam. Her renal function remained stable for a time (serum creatinine 0.5 mg/dL, blood urea nitrogen 10 mg/dL, urine output 100–200 mL/h). However, after several more days, the patient's condition deteriorated, and she ultimately died.DISCUSSION:Previous cases of propylene glycol toxicity secondary to high-dose lorazepam infusion have occurred in patients with compromised renal function. Our patient's renal function remained stable throughout the hospital course, which caused us to look further for an explanation for the propylene glycol–induced lactic acidosis. Based on the Naranjo probability scale, propylene glycol was determined to be the probable cause of lactic acidosis. Since this case occurred, our intensive care unit has instituted recommendations for the prevention of lorazepam-associated propylene glycol toxicity.CONCLUSIONS:Our case highlights the development of propylene glycol–induced lactic acidosis secondary to high-dose lorazepam infusion not associated with renal dysfunction.
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Affiliation(s)
- Bruce W Neale
- Department of Pharmacy, Fletcher Allen Health Care, Burlington, VT 05401-1473, USA
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Riker RR, Fraser GL. Adverse Events Associated with Sedatives, Analgesics, and Other Drugs That Provide Patient Comfort in the Intensive Care Unit. Pharmacotherapy 2005; 25:8S-18S. [PMID: 15899744 DOI: 10.1592/phco.2005.25.5_part_2.8s] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Since the 2002 publication of multidisciplinary clinical practice guidelines for intensive care unit (ICU) sedation and analgesia, additional information regarding adverse drug events has been reported. Our understanding of the risks associated with these sedative and analgesic agents promises to improve outcomes by helping clinicians identify and respond to therapeutic misadventures sooner. This review focuses on many issues, including the potentially fatal consequences associated with the propofol infusion syndrome, the evolving understanding of propylene glycol intoxication associated with parenteral lorazepam, new data involving high-dose and long-term dexmedetomidine therapy, haloperidol- and methadone-related prolongation of QTc intervals on the electrocardiogram, adverse events associated with atypical antipsychotics, and the potential for nonsteroidal antiinflammatory drugs to interfere with bone healing.
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Affiliation(s)
- Richard R Riker
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Maine Medical Center, Portland, Maine 04102, USA
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Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults*. Crit Care Med 2004; 32:1709-14. [PMID: 15286548 DOI: 10.1097/01.ccm.0000134831.40466.39] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The primary objective was to evaluate the relationship between high-dose lorazepam and serum propylene glycol concentrations. Secondary objectives were a) to document the occurrence of propylene glycol accumulation associated with continuous high-dose lorazepam infusion; b) to assess the relationship between lorazepam dose, serum propylene glycol concentrations, and propylene glycol accumulation; and c) to assess the relationship between the osmol gap and serum propylene glycol concentrations. DESIGN Prospective, observational study. SETTING Tertiary care, medical intensive care unit. PATIENTS Nine critically ill adults receiving high-dose lorazepam (> or =10 mg/hr) infusion. INTERVENTIONS Cumulative lorazepam dose (mg/kg) and the rate of infusion (mg.kg(-1).hr(-1)) were monitored from initiation of lorazepam infusion until 24 hrs after discontinuation of the high-dose lorazepam infusion. Serum osmolarity was collected at 48 hrs into the high-dose lorazepam infusion and daily thereafter. Serum propylene glycol concentrations were drawn at 48 hrs into the high-dose lorazepam infusion, and the presence of propylene glycol accumulation, as evidenced by a high anion gap (> or =15 mmol/L) metabolic acidosis with elevated osmol gap (> or =10 mOsm/L), was assessed at that time. MEASUREMENTS AND MAIN RESULTS The mean cumulative high-dose lorazepam received and mean high-dose lorazepam infusion rate were 8.1 mg/kg (range, 5.1-11.7) and 0.16 mg.kg(-1).hr (-1)(range, 0.11-0.22), respectively. A significant correlation between high-dose lorazepam infusion rate and serum propylene glycol concentrations was observed (r =.557, p =.021). Osmol gap was the strongest predictor of serum propylene glycol concentrations (r =.804, p =.001). Propylene glycol accumulation was observed in six of nine patients at 48 hrs. No significant correlation between duration of lorazepam infusion and serum propylene glycol concentrations was observed (p =.637). CONCLUSION Propylene glycol accumulation, as reflected by a hyperosmolar anion gap metabolic acidosis, was observed in critically ill adults receiving continuous high-dose lorazepam infusion for > or =48 hrs. Study findings suggest that in critically ill adults with normal renal function, serum propylene glycol concentrations may be predicted by the high-dose lorazepam infusion rate and osmol gap.
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Affiliation(s)
- Alejandro C Arroliga
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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NTP-CERHR Expert Panel report on the reproductive and developmental toxicity of propylene glycol. Reprod Toxicol 2004; 18:533-79. [PMID: 15135851 DOI: 10.1016/j.reprotox.2004.01.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Yaucher NE, Fish JT, Smith HW, Wells JA. Propylene Glycol–Associated Renal Toxicity from Lorazepam Infusion. Pharmacotherapy 2003; 23:1094-9. [PMID: 14524641 DOI: 10.1592/phco.23.10.1094.32762] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Using data from patients who developed elevations in serum creatinine concentrations while receiving continuous-infusion lorazepam, we sought to determine the correlations between the magnitude of serum creatinine concentration rise and each of the following variables: serum propylene glycol level, cumulative lorazepam dose, and duration of lorazepam administration. An additional objective was to identify clinical markers for propylene glycol toxicity. DESIGN Retrospective chart review. SETTING Medical-surgical intensive care unit and burn unit at a university hospital. PATIENTS Eight patients who developed elevations in serum creatinine concentrations while receiving continuous-infusion lorazepam (range 2-28 mg/hr). MEASUREMENTS AND MAIN RESULTS The mean cumulative dose of lorazepam was 4305 mg (range 1200-10,920 mg), and the mean propylene glycol level determined at the time of peak serum creatinine concentration was 1103 microg/ml (range 186-3450 microg/ml). Serum creatinine concentrations increased in all eight patients during lorazepam infusion and decreased in seven within 3 days after stopping infusion. A weak-to-moderate correlation existed between the magnitude of the rise in serum creatinine concentration and propylene glycol level (r=0.53). A weak-to-moderate correlation also was identified between cumulative lorazepam dose and magnitude of serum creatinine concentration rise (r=0.43), and a strong-to-moderate correlation was found between duration of lorazepam infusion and magnitude of serum creatinine concentration rise (r=0.60). Propylene glycol levels were strongly correlated with both serum osmolality and osmol gap. CONCLUSION The patients' increased serum creatinine concentrations are likely to have resulted from exposure to propylene glycol as a result of lorazepam infusion. Serum osmolality and osmol gap may be useful markers for propylene glycol toxicity.
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Hayman M, Seidl EC, Ali M, Malik K. Acute Tubular Necrosis Associated with Propylene Glycol from Concomitant Administration of Intravenous Lorazepam and Trimethoprim-Sulfamethoxazole. Pharmacotherapy 2003; 23:1190-4. [PMID: 14524651 DOI: 10.1592/phco.23.10.1190.32753] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 46-year-old morbidly obese man was admitted to the medical intensive care unit with respiratory failure. He required pressure-control ventilation and high levels of sedation with continuous-infusion lorazepam. He developed Stenotrophomonas maltophilia pneumonia; treatment included scheduled intravenous trimethoprim-sulfamethoxazole. Each of these drugs contain several hundred milligrams/milliliter of propylene glycol. On day 17 of his hospital course, 3 days after starting the trimethoprim-sulfamethoxazole, the patient developed acute renal failure consistent with acute tubular necrosis. Propylene glycol toxicity was suspected; therefore, all drugs containing propylene glycol were discontinued, and laboratory data were collected. A marked osmol gap, metabolic acidosis, and renal toxicity were attributed to both continuous and large intermittent doses of intravenous propylene glycol. Particular attention should be paid to the total amount of propylene glycol provided to patients from administered drugs. Patients in the intensive care setting who require high doses of intravenous lorazepam for sedation, as well as antimicrobial therapy with trimethoprim-sulfamethoxazole for treatment of either Stenotrophomonas maltophilia or Pneumocystis carinii pneumonia, may be at increased risk for propylene glycol toxicity and should be monitored closely.
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Affiliation(s)
- Marybeth Hayman
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA.
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Abstract
This article focuses on the epidemiology, pathogenesis, and prevention of the most common forms of acute renal failure encountered in the critically ill. These include pre-renal azotemia and acute tubular necrosis that occurs postoperatively, in patients with rhabdomyolysis, or as a complication of sepsis. In addition, some unusual causes of acute renal failure that occur predominantly in the intensive care unit are briefly discussed.
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Affiliation(s)
- Vivian E Abernethy
- Boston University School of Medicine, Renal Section, Evans Biomedical Research Center, 5th Floor, Room 537, 650 Albany Street, Boston, MA 02118, USA
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Wieslander G, Norbäck D, Lindgren T. Experimental exposure to propylene glycol mist in aviation emergency training: acute ocular and respiratory effects. Occup Environ Med 2001; 58:649-55. [PMID: 11555686 PMCID: PMC1740047 DOI: 10.1136/oem.58.10.649] [Citation(s) in RCA: 141] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Propylene glycol (PG) (1-2 propanediol; CAS No 57-55-6) is a low toxicity compound widely used as a food additive, in pharmaceutical preparations, in cosmetics, and in the workplace-for example, water based paints, de-icing fluids, and cooling liquids. Exposure to PG mist may occur from smoke generators in discotheques, theatres, and aviation emergency training. Propylene glycol may cause contact allergy, but there is sparse information on health effects from occupational exposure to PG. METHODS Non-asthmatic volunteers (n=27) were exposed in an aircraft simulator to PG mist over 1 minute, during realistic training conditions. Geometric mean concentration of PG was 309 mg/m3 (range 176-851 mg/m3), with the highest concentrations in the afternoon. The medical investigation was performed both before and after the exposure (within 15 minutes). It included an estimate of tear film stability break up time, nasal patency by acoustic rhinometry, dynamic spirometry, and a doctor's administered questionnaire on symptoms. RESULTS After exposure to PG mist for 1 minute tear film stability decreased, ocular and throat symptoms increased, forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) was slightly reduced, and self rated severity of dyspnoea was slightly increased. No effect was found for nasal patency, vital capacity (VC), FVC, nasal symptoms, dermal symptoms, smell of solvent, or any systemic symptoms. Those exposed to the higher concentrations in the afternoon had a more pronounced increase of throat symptoms, and a more pronounced decrease of tear film stability. In four subjects who reported development of irritative cough during exposure to PG, FEV1 was decreased by 5%, but FEV1 was unchanged among those who did not develop a cough. Those who developed a cough also had an increased perception of mild dyspnoea. CONCLUSION Short exposure to PG mist from artificial smoke generators may cause acute ocular and upper airway irritation in non-asthmatic subjects. A few may also react with cough and slight airway obstruction.
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Affiliation(s)
- G Wieslander
- Department of Medical Sciences/Occupational and Environmental Medicine, Uppsala University, University Hospital, S-751 85, Uppsala, Sweden.
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