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Huber S, Avera R, Penfound S, Overberg A, Nañagas K. Safety of Physostigmine for Pediatric Antimuscarinic Poisoning. J Med Toxicol 2024; 20:263-270. [PMID: 38265619 PMCID: PMC11288213 DOI: 10.1007/s13181-024-00988-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/30/2023] [Accepted: 01/05/2024] [Indexed: 01/25/2024] Open
Abstract
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.
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Affiliation(s)
- Sarah Huber
- Indiana University School of Medicine, Indianapolis, IN, USA
- IU Health Methodist Hospital, 1701 North Senate Blvd. B412b, Indianapolis, IN, 46234, USA
| | - Robert Avera
- Indiana University School of Medicine, Indianapolis, IN, USA
- IU Health Methodist Hospital, 1701 North Senate Blvd. B412b, Indianapolis, IN, 46234, USA
- Indiana University Health - Academic Health Center, Indianapolis, IN, USA
- Indiana Poison Center, Indianapolis, IN, USA
| | - Shannon Penfound
- IU Health Methodist Hospital, 1701 North Senate Blvd. B412b, Indianapolis, IN, 46234, USA
- Indiana Poison Center, Indianapolis, IN, USA
| | - Adam Overberg
- Indiana University School of Medicine, Indianapolis, IN, USA
- IU Health Methodist Hospital, 1701 North Senate Blvd. B412b, Indianapolis, IN, 46234, USA
- Indiana University Health - Academic Health Center, Indianapolis, IN, USA
- Indiana Poison Center, Indianapolis, IN, USA
| | - Kristine Nañagas
- Indiana University School of Medicine, Indianapolis, IN, USA.
- IU Health Methodist Hospital, 1701 North Senate Blvd. B412b, Indianapolis, IN, 46234, USA.
- Indiana University Health - Academic Health Center, Indianapolis, IN, USA.
- Indiana Poison Center, Indianapolis, IN, USA.
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Chung J, Tjia J, Zhang N, O'Connor BT. Anticholinergic Burden and Xerostomia in Critical Care Settings. Dimens Crit Care Nurs 2023; 42:310-318. [PMID: 37756502 DOI: 10.1097/dcc.0000000000000606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023] Open
Abstract
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.
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Cui N, Zhang H, Gan S, Zhang Y, Chen D, Guo P, Wu J, Li Z, Jin J. Prevalence and Influencing Factors of Physical Restraints in Intensive Care Units: A Retrospective Cohort Study. Risk Manag Healthc Policy 2023; 16:945-956. [PMID: 37228847 PMCID: PMC10204753 DOI: 10.2147/rmhp.s408919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/13/2023] [Indexed: 05/27/2023] Open
Abstract
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.
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Affiliation(s)
- Nianqi Cui
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang, People’s Republic of China
- School of Nursing, Kunming Medical University, Kunming, Yunnan, People’s Republic of China
| | - Hui Zhang
- Department of Cardiology, Guizhou Provincial People’s Hospital, Guiyang, Guizhou, People’s Republic of China
| | - Sijie Gan
- Product Development Center, Zhejiang Xinhua Mobile Media Co. Ltd, Hangzhou, Zhejiang, People’s Republic of China
| | - Yuping Zhang
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang, People’s Republic of China
| | - Dandan Chen
- Faculty of Nursing, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
| | - Pingping Guo
- Faculty of Nursing, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
| | - Jingjie Wu
- Faculty of Nursing, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
| | - Zhuang Li
- Medical Faculty, Yunnan College of Business Management, Kunming, Yunnan, People’s Republic of China
| | - Jingfen Jin
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang, People’s Republic of China
- Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
- Dean’s Office, Changxing Branch Hospital of SAHZU, Huzhou, Zhejiang, People’s Republic of China
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Dawson A. Physostigmine should be used more readily for antimuscarinic toxicity: PRO. Br J Clin Pharmacol 2021; 88:58-60. [PMID: 34705298 DOI: 10.1111/bcp.15120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew Dawson
- NSW Poisons Information Centre, Westmead Childrens Hospital, Sydney, Australia.,Central Clinical School, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
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Blackstone NG, Olson A, Ainapurapu B. Physostigmine in Anticholinergic Poisoning: An Old Antidote With Resurgence. Cureus 2020; 12:e11739. [PMID: 33403170 PMCID: PMC7773307 DOI: 10.7759/cureus.11739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
| | - April Olson
- Internal Medicine, University of Arizona College of Medicine - Tucson, Tucson, USA
| | - Bujji Ainapurapu
- Internal Medicine, University of Arizona College of Medicine - Tucson, Tucson, USA
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