Priapism in a patient treated with total parenteral nutrition

Intravenous lipid emulsion for the treatment of poisonings in 313 dogs and 100 cats (2016-2020)

Introduction

The aim of this retrospective study was to analyze the effect and potential adverse effects of intravenous lipid emulsion (ILE) in poisoned dogs and cats over a 5 years period.

Methods

Medical records of 313 dogs and 100 cats receiving ILE between 2016-2020 were analyzed for suspected toxicant, clinical signs, ILE dosages and frequency, the effect and adverse effects of ILE, and patient outcome.

Results

Dogs and cats were poisoned with mostly unidentified toxicants (48%), rodenticides (8%), recreational drugs and nuts (7% each) and other toxicants. Clinical signs included neurologic deficits (63%), cardiovascular signs (29%), thermoregulation (21%) or gastrointestinal abnormalities (17%). Treatment with ILE was initiated within a median of 6.0 h (1.0-91.0 h) after poisoning. Dogs and cats received a total amount of median 8.0 mL/kg (1.5-66.6 mL/kg) and 15.8 mL/kg (1.8-69.4 mL/kg) ILE, respectively. A positive effect was observed in 74% of the patients, whereas clinical signs worsened in 4% of the patients after ILE administration. No subjective effect was detected in 22% of the patients. Suspected or possible adverse effects of ILE occurred in 6% of the patients, including neurological signs (temporarily reduced consciousness and ataxia), bradycardia, hyperthermia, vomiting, diarrhea, respiratory distress, worsening of the general behavior, facial swelling, and thrombophlebitis. The overall survival rate was 96%. One dog who potentially experienced adverse events was euthanized.

Conclusion

ILE treatment was successful in most patients but can be associated with adverse effects. Administration of ILE should be carefully selected on an individual basis after weighing the possible benefits against potential adverse effects.

The first case of neonatal priapism during hypothermia for hypoxic-ischemic encephalopathy and a literature review

Neonatal priapism is a rare condition with only 26 described cases in literature since 1879. It is defined as a persistent penile erection occurring in the first 28 days of life, lasting at least 4 h that usually happens in the first days (from 2 to 12 days). It is a very different condition compared to the adult one because in newborns it is a relatively benign phenomenon. As a result of this paucity of described cases, classification and management are not well known by most of neonatologists and currently there are no established guidelines for its management. Most cases are idiopathic but other aetiologies are possible (polycythemia, blood transfusion and drugs). We describe our only case, which occurred during hypothermia therapy and review the literature to clarify the best choice in management of this rare entity.

Systematic review of clinical adverse events reported after acute intravenous lipid emulsion administration

BACKGROUND

Intravenous lipid emulsions (ILEs) were initially developed to provide parenteral nutrition. In recent years, ILE has emerged as a treatment for poisoning by local anesthetics and various other drugs. The dosing regimen for the clinical toxicology indications differs significantly from those used for parenteral nutrition. The evidence on the efficacy of ILE to reverse acute toxicity of diverse substances consists mainly of case reports and animal experiments. Adverse events to ILE are important to consider when clinicians need to make a risk/benefit analysis for this therapy.

METHODS

Multiple publication databases were searched to identify reports of adverse effects associated with acute ILE administration for either treatment of acute poisoning or parenteral nutrition. Articles were selected based on pre-defined criteria to reflect acute use of ILE. Experimental studies and reports of adverse effects as a complication of long-term therapy exceeding 14 days were excluded.

RESULTS

The search identified 789 full-text articles, of which 114 met the study criteria. 27 were animal studies, and 87 were human studies. The adverse effects associated with acute ILE administration included acute kidney injury, cardiac arrest, ventilation perfusion mismatch, acute lung injury, venous thromboembolism, hypersensitivity, fat embolism, fat overload syndrome, pancreatitis, extracorporeal circulation machine circuit obstruction, allergic reaction, and increased susceptibility to infection.

CONCLUSION

The emerging use of ILE administration in clinical toxicology warrants careful attention to its potential adverse effects. The dosing regimen and context of administration leading to the adverse events documented in this review are not generalizable to all clinical toxicology scenarios. Adverse effects seem to be proportional to the rate of infusion as well as total dose received. Further safety studies in humans and reporting of adverse events associated with ILE administration at the doses advocated in current clinical toxicology literature are needed.

Reduced risk of pulmonary emboli in children treated with long-term parenteral nutrition

BACKGROUND & AIMS

Pulmonary embolism (PE) is a complication of parenteral nutrition (PN) with a prevalence of 35% in children. In 2003 new intravenous lipid emulsions (ILEs) with MCT, olive and/or fish oil in addition to soybean oil were introduced. The aim was to compare the incidence of PE before and after introduction.

METHODS

327 surveillance ventilation-perfusion (V/Q) scintigraphies from 68 children aged 0.3-15 years, treated with PN from 1993 to 2010, were retrospectively reviewed. Rate of PE/1000 central venous catheter (CVC) days, number of children with PE pre- and post-introduction of ILEs were compared. Multivariate analyses were performed for risk factors.

RESULTS

Twenty-two (32%) children (19/42 before 2003 and 3/26 after 2003, p = 0.007) had at least one episode of PE. Thirty seven (11%) episodes of PE were detected accounting for a mean of 0.2/1000 CVC days prior to 2003 and 0.05/1000 CVC days after 2003, p = 0.04. Regression analysis indicated that higher content of ILE/infusion (p = 0.045) and frequency of ILE of >3 nights/week were associated with more PE (p = 0.001). New ILEs were associated with lower risk (p = 0.003).

CONCLUSION

With a four-fold fall in incidence with new ILE, PE remains a complication. We recommend 12-18 monthly surveillance with lung perfusion scan and anticoagulants if PE is diagnosed.

A pathophysiology-based approach to the management of early priapism

Priapism is a rare condition that involves persistent penile erection for greater than 4 h. Distinct variants exist, each with unique characteristics. Ischemic priapism is a painful medical emergency that may occur as a result of veno-occlusion leading to hypoxia and tissue death. Recurrent bouts of ischemic priapism, or stuttering priapism, require treatment for individual attacks as well as long-term prevention. Non-ischemic priapism is associated with trauma and may be managed conservatively. Recent advances into the pathophysiology of priapism have allowed the development of treatment algorithms that specifically target the mechanisms involved. In this review, we outline the basics of smooth muscle contraction and describe how derangement of these pathways results in priapism. A pathophysiological approach to the treatment of priapism is proposed with duration-based algorithms presented to assist in management.

Evaluation and management of priapism: 2009 update

Priapism is defined as a persistent penile erection (typically 4 h or longer) that is unrelated to sexual stimulation. Priapism can be classified as either ischemic or nonischemic. Ischemic priapism, the most common subtype, is typically accompanied by pain and is associated with a substantial risk of subsequent erectile dysfunction. Prompt medical attention is indicated in cases of ischemic priapism. The initial management of choice is corporal aspiration with injection of sympathomimetic agents. If medical management fails, a cavernosal shunt procedure is indicated. Stuttering (recurrent) ischemic priapism is a challenging and poorly understood condition; new management strategies currently under investigation may improve our ability to care for men with this condition. Nonischemic priapism occurs more rarely than ischemic priapism, and is most often the result of trauma. This subtype of priapism, which is generally not painful, is usually initially managed with conservative treatment.

Idiopathic low-flow priapism in prepuberty: a case report and a review of literature

Introduction. The incidence of priapism in adults is higher than in children. Although approximately 50% of all episodes of priapism are thought to be idiopathic, there are a number of known specific causes of this disorder. In adults intracavernous therapy with papaverine, phentolamine, alprostadil or combinations of these agents is the most common cause of ischemic priapism. In children the most common etiology is sickle cell anemia for low-flow priapism or post-traumatic high-flow priapism. We present a 13-year-old boy, not sexually active presented to our outpatient clinic suffering from long standing (3.5 hours) sustained painful erection. To the best of our knowledge the idiopathic low-flow priapism in pre-pubertal boy was not reported before in literature. Our case is the first case to be reported in pre-pubertal age. Conclusion. In pre-pubertal boys idiopathic recurrent priapism is a rare condition. In the literature, several empirical therapies are described. Recently, it is postulated that a low dose of a PDE5 inhibitor. The early conservative management is the best treatment option to safe the corporeal smooth muscles from irreversible damage.

Propofol-Induced Priapism, a Case Confirmed with Rechallenge

Objective:

To report a case of propofol-induced priapism.

Case Summary:

A 17-year-old male receiving propofol for induction of anesthesia during a cardiac ablation procedure developed priapism that required medical intervention and discontinuation of propofol. The priapism developed after a total propofol dose of 550 mg, lasted for 2 hours, and resolved immediately following medical intervention. The following day, the patient underwent a transesophageal echocardiogram and received a total propofol dose of 40 mg throughout the procedure. He again developed priapism, which resolved within one hour without medical intervention.

Discussion:

Priapism experienced by this patient is considered to be drug-induced because of the temporal relationship, recurrence with rechallenge, and dose–response relationship. Using the Naranjo probability scale, we determined that propofol was a highly probable causative agent of priapism in this patient.

Conclusions:

Although, as of April 4, 2006, this adverse effect has not been previously reported, there is a strong correlation of propofol to priapism in this patient. Clinicians should be aware of this adverse effect.

Therapy insight: Priapism associated with hematologic dyscrasias

Priapism is defined as a genuine erectile disorder, in which erection persists uncontrollably without sexual purpose. This disorder is often overlooked in comparison to other male sexual dysfunctions, principally because of its seeming rarity. Priapism, however, occurs frequently in certain patient populations, including those with hematologic dyscrasias. Most commonly, priapism affects patients with sickle cell disease. The reported prevalence rate in this group ranges between 29% and 42% of males. The significance of priapism is further emphasized by the fact that this disorder commonly causes erectile tissue damage and leads to the loss of functional erections. These observations highlight the need for proper clinical recognition of priapism in order to enable appropriate management. Here, the current knowledge of priapism as it relates to hematologic and coagulative diseases is discussed, with a focus on the diagnosis and treatment of the disorder.

Priapism

Priapism is a relatively uncommon condition that may present as a medical emergency associated with significant pain and anxiety in the veno-occlusive or low-flow variant. Pharmacologic advances and, specifically, the availability of intracavemosal alpha-agonist therapy have dramatically improved the prospects of resolution for patients with low-flow priapism presenting within the first few hours of the acute episode. High-flow priapism is not considered an emergency and treatment measures are typically conservative aimed at preservation of potency. Urologists, radiologists, and other health care personnel caring for the patient with priapism must be familiar with various etiologic factors implicated in low-flow and high-flow priapism to formulate a logical step-care approach. Differentiation of the low-flow from the high-flow state is perhaps the most critical initial diagnostic challenge that determines the sequence of further interventions including surgical shunts in low-flow priapism refractory to medical therapy.

The etiology, diagnosis, and treatment of priapism: review of the American Foundation for Urologic Disease Consensus Panel Report

Priapism is an important medical condition that requires immediate evaluation, and depending on etiology, may require emergency management. Based on the classification scheme offered by a recent consensus panel, priapism can be subdivided into ischemic and nonischemic types. The nonischemic type, usually the result of perineal trauma, can be treated with conservative therapy, whereas the nonischemic type, which arises from many varied causes, mandates immediate intervention. Corporal fibrosis and permanent erectile dysfunction can result from ischemic priapism that fails to resolve with therapy.