A Comparison of Resource Utilization in the Management of Anticholinergic Delirium Between Physostigmine and Nonantidote Therapy

Safety of Physostigmine for Pediatric Antimuscarinic Poisoning

INTRODUCTION

Physostigmine fell out of widespread use in the 1980s due to safety concerns; however, more recent research has demonstrated that its safety profile is better than previously thought. These studies have mainly included adults. We theorized that improved safety data may lead to more acceptance. Our objectives, therefore, were to characterize current frequency of use of physostigmine in pediatric patients as well as to study adverse effect rates in a national pediatric patient population.

METHODS

The National Poison Data System was queried for cases of patients aged 0-18 years that involved single-substance exposures to antimuscarinic xenobiotics that were reported to a poison center between January 1, 2000, and December 31, 2020. Cases were stratified into groups by therapy received: benzodiazepines alone, benzodiazepines and physostigmine, physostigmine alone, or no physostigmine or benzodiazepines. Patient demographics, clinical effects, and medical outcomes were analyzed.

RESULTS

A total of 694,132 cases were reviewed, and 150,075 were included for analysis. Nearly 5% (7562/150,075) of patients received specific pharmacological therapy with benzodiazepines, physostigmine, or both. A benzodiazepine as a single agent was the most frequently used pharmacologic therapy (92% of 7562). Among patients receiving any pharmacological therapy, only 8.3% (n = 627) of patients received physostigmine. Frequency of serious outcomes significantly increased across the study period among patients receiving benzodiazepines alone or with physostigmine. There was no increase in serious outcomes among patients receiving only physostigmine.

CONCLUSIONS

Physostigmine frequency of use was low overall, but when used, was associated with less severe outcomes when compared to benzodiazepines.

Anticholinergic Burden and Xerostomia in Critical Care Settings

BACKGROUND

Although previous studies have established the association of medications with anticholinergic adverse effects and xerostomia, anticholinergic burden and xerostomia in critical care settings are poorly characterized. The objective of this study was to determine the impact of medication burdens associated with anticholinergic adverse effects, particularly the occurrence of xerostomia (dry mouth) in a critical care setting. In addition, this study explored the correlation between the timing of the first instance of xerostomia and the administration timing of medication known to have anticholinergic adverse effects.

METHODS

A retrospective case-control study was used with the MIMIC (Medical Information Mart for Intensive Care) III database. The MIMIC-III clinical database is a publicly available, deidentified, health-related database with more than 40 000 patients in critical care units from 2001 to 2012. Cases of xerostomia (n = 1344) were selected from clinical notes reporting "dry mouth," "xerostomia," or evidence of pharmacological treatment for xerostomia; control (n = 4032) was selected using the propensity analysis with 1:3 matching on covariates (eg, age, sex, race, ethnicity, and length of stay). The anticholinergic burden was quantified as the cumulative effect of anticholinergic activities using the Anticholinergic Burden Scale.

RESULTS

Anticholinergic burden significantly differed between xerostomia patients and control subjects (P = .04). The length of stay was a statistically significant factor in xerostomia. The probability of developing the symptom of xerostomia within 24 hours was .95 (95%) for patients of xerostomia.

CONCLUSIONS

Anticholinergic Burden Scale is associated with xerostomia in the critical care setting, particularly within 24 hours after admission. It is crucial to carefully evaluate alternative options for medications that may have potential anticholinergic adverse effects. This evaluation should include assessing the balance between the benefits and harms, considering the probability of withdrawal reactions, and prioritizing deprescribing whenever feasible within the initial 24-hour period.

Prevalence and Influencing Factors of Physical Restraints in Intensive Care Units: A Retrospective Cohort Study

Purpose

Physical restraints are used routinely in intensive care units (ICUs) and have negative effects. It is critical to identify the impact factors of physical restraints on critically ill patients. The present study investigated the prevalence of physical restraints and impact factors associated with their use in a large cohort of critically ill patients over one year.

Patients and Methods

A retrospective cohort study was performed in multiple ICUs at a tertiary hospital in China in 2019 using observational data from electronic medical records. The data consisted of demographics and clinical variables. Logistic regression was used to assess the independent impact factors for the use of physical restraint.

Results

The analysis consisted of 3776 critically ill patients with a prevalence of physical restraint use of 48.8%. The logistic regression analysis indicated that physical restraint use was associated with independent risk factors, including surgical ICU admission, pain, tracheal tube placement, and abdominal drainage tube placement. Physical restraint use was associated with independent protective factors, including male sex, light sedation, muscle strength, and ICU length of stay.

Conclusion

The prevalence of physical restraint use in critically ill patients was high. Tracheal tubes, surgical ICU, pain, abdominal drainage tubes, light sedation, and muscle strength were independent variables associated with the use of physical restraint. These results will assist health professionals in identifying high-risk physical restraint patients based on their impact factors. Early removal of the tracheal tube and abdominal drainage tube, pain relief, light sedation, and improvements in muscle strength may help reduce the use of physical restraints.

Physostigmine should be used more readily for antimuscarinic toxicity: PRO

Physostigmine is the preferred treatment for antimuscarinic toxicity. Its use has a clear biological rationale and is supported by extensive clinical use which demonstrated effectiveness and safety.

Physostigmine in Anticholinergic Poisoning: An Old Antidote With Resurgence

Physostigmine is a cholinesterase inhibitor used therapeutically in patients with anticholinergic delirium that is so severe that intubation may be required for airway protection. Given that a wide variety of medications have anticholinergic properties, and the current standard of care is typically a central nervous system depressant, hospitalizations are often lengthy and normally require a critical-care level of attention. Despite this, physostigmine is often underutilized and poorly understood in the clinical setting. We report a case of a 43-year-old female who presented to the emergency department one hour after ingesting approximately 150 tablets of diphenhydramine in a suicide attempt. She was treated with benzodiazepines with minimal success, and airway protection became imminent as her mentation continued to decline. Through the use of physostigmine, we were able to save this patient from endotracheal intubation and the potential complications of mechanical ventilation.