1
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Kk A, Reddy SPC, N PK, Nayak-Rao S. Successful use of hemoperfusion in phenobarbitone poisoning. Ther Apher Dial 2024. [PMID: 39210591 DOI: 10.1111/1744-9987.14201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 07/30/2024] [Accepted: 08/16/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Athish Kk
- Department of Physiology, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
| | - Sangam Prem Chandar Reddy
- Department of General Medicine, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
| | - Prasanna Kumar N
- Department of Nephrology, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
| | - Shobhana Nayak-Rao
- Department of Nephrology, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
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2
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Seltzer J, Hardin J, Galust H, Friedman N, Corbett B, Clark RF. Pharmacokinetic analysis of a phenobarbital overdose treated with urinary alkalinization alone. Toxicol Rep 2024; 12:574-577. [PMID: 38798988 PMCID: PMC11127027 DOI: 10.1016/j.toxrep.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/27/2024] [Accepted: 05/14/2024] [Indexed: 05/29/2024] Open
Abstract
Phenobarbital is a long-acting barbiturate used to treat alcohol withdrawal and epilepsy. Acute overdoses present with varying levels of central nervous system depression and large overdoses can be life threatening. Phenobarbital is an attractive candidate for enhanced elimination using urinary alkalinization given it is a weak acid with a long half-life and extensive urinary elimination. Limited human data exist regarding use of urine alkalinization for the treatment of phenobarbital overdose. We present a fourteen-year-old female who was treated with urinary alkalinization alone following an intentional ingestion of 3800 mg (84.4 mg/kg) of phenobarbital tablets. Urine drugs of abuse screening was preliminary positive for barbiturates and confirmed to be phenobarbital only. The initial serum phenobarbital concentration, drawn nine hours post-ingestion, was 97.4 mcg/ml (normal range 15-40 mcg/ml). Urinary alkalinization with sodium bicarbonate was started approximately 12 h post-ingestion and stopped at 72 h post-ingestion; clinical toxicity resolved by hospital day 5. The infusion was titrated to a urinary pH of greater than 7.5. Serial serum and urine phenobarbital measurements were obtained to determine elimination half-life and urinary excretion. The elimination half-life while undergoing urinary alkalinization was 81.3 h. Prior to initiation of urinary alkalinization, the urine phenobarbital concentration was 37 mcg/ml. Approximately 8.75 h after initiation, it was greater than 200 mcg/ml at a urine pH of 8.5. Urinary alkalinization appeared to augment urinary phenobarbital excretion, though with no discernible effect on elimination half-life and unclear clinical benefit. Further research is needed to better characterize the clinical effects of urinary alkalinization for phenobarbital overdose.
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Affiliation(s)
- Justin Seltzer
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, CA, USA
| | - Jeremy Hardin
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- San Diego Division, California Poison Control System, San Diego, CA, USA
| | - Henrik Galust
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- San Diego Division, California Poison Control System, San Diego, CA, USA
| | | | - Bryan Corbett
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, CA, USA
| | - Richard F. Clark
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, CA, USA
- San Diego Division, California Poison Control System, San Diego, CA, USA
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3
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Nieto Piñar Y, Sala Carazo M, Barceló Martín B. [Use of continuous venovenous hemodiafiltration in a case of severe pentobarbital poisoning]. Med Clin (Barc) 2023; 161:178-179. [PMID: 37296045 DOI: 10.1016/j.medcli.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/04/2023] [Accepted: 04/09/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Yasmina Nieto Piñar
- Servicio de Medicina Intensiva, Hospital Universitario Son Llàtzer, Palma de Mallorca (Islas Baleares), España
| | - Maria Sala Carazo
- Servicio de Medicina Intensiva, Hospital Universitario Son Llàtzer, Palma de Mallorca (Islas Baleares), España
| | - Bernardino Barceló Martín
- Unidad de Toxicología Clínica, Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma de Mallorca (Islas Baleares), España; Grupo de Investigación en Toxicología Clínica, Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa) , Palma de Mallorca (Islas Baleares), España; Departamento de Medicina, Facultad de Medicina, Universidad de las Islas Baleares, Palma de Mallorca (Islas Baleares), España.
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4
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Ke S, Lian R, Wang R, Rao Y, Liang C, Liang J, Zhang Y. Rapid quantification of phenobarbital and barbital in human whole blood by liquid-liquid extraction combined with DART-orbitrap-HRMS. Forensic Toxicol 2023; 41:126-134. [PMID: 36652071 DOI: 10.1007/s11419-022-00650-w] [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: 05/24/2022] [Accepted: 10/27/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE This study aims to develop and validate a rapid, simple, and efficient bioanalytical method for the simultaneous quantification of phenobarbital and barbital in human whole blood using liquid-liquid extraction combined with direct analysis in real time (DART) and high-resolution mass spectrometry (HRMS). METHOD Phenobarbital-d5 and aprobarbital were selected as internal standards (ISs) of phenobarbital and barbital, respectively. A mixed solvent of o-xylene and ethyl acetate at a ratio of 1:6 was used to extract analytes of interest and ISs from 100 μL of human whole blood samples. Phenobarbital and barbital were detected by DART-HRMS. The proposed method has been validated in accordance with United States Food and Drug Administration Guidelines for Bioanalytical Method Validation in terms of selectivity, linearity, accuracy, precision, matrix effect, recovery, stability, and dilution integrity. RESULTS The lower limits of quantification (LLOQs) of phenobarbital and barbital were both 10 ng/mL. The linearities were in the range of 10-1000 ng/mL (R2 ≥ 0.99). The mean recovery values of phenobarbital and barbital were 99.7% and 88.1%, respectively. The interday and intraday precision values were less than 10.4%, and the interday and intraday accuracy values ranged from 87.6 to 106.7%. Furthermore, the validated method was applied to four cases of phenobarbital poisoning at the Shanghai Institute of Forensic Science. CONCLUSION The developed and fully validated method enabled the simultaneous quantification of phenobarbital and barbital in human whole blood and was successfully applied to authentic cases.
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Affiliation(s)
- Shi Ke
- Department of Pharmaceutical Analysis, School of Pharmacy, Fudan University, Shanghai, 201203, China
- State Key Laboratory of New Drug and Pharmaceutical Process, China State Institute of Pharmaceutical Industry, Shanghai, 200040, China
- Shanghai Key Laboratory of Crime Scene Evidence, Shanghai Institute of Forensic Science, Shanghai, 200083, China
| | - Ru Lian
- Shanghai Key Laboratory of Crime Scene Evidence, Shanghai Institute of Forensic Science, Shanghai, 200083, China
| | - Rong Wang
- Shanghai Key Laboratory of Crime Scene Evidence, Shanghai Institute of Forensic Science, Shanghai, 200083, China
| | - Yulan Rao
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, People's Republic of China
| | - Chen Liang
- Shanghai Key Laboratory of Crime Scene Evidence, Shanghai Institute of Forensic Science, Shanghai, 200083, China
| | - Jianying Liang
- Department of Pharmaceutical Analysis, School of Pharmacy, Fudan University, Shanghai, 201203, China.
| | - Yurong Zhang
- Shanghai Key Laboratory of Crime Scene Evidence, Shanghai Institute of Forensic Science, Shanghai, 200083, China.
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5
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Trinder R, Greensmith T, Cole L, Cortellini S. The use of haemodialysis for the treatment of phenobarbitone intoxication 30 h after ingestion. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Richard Trinder
- Department of Clinical Science and Services The Royal Veterinary College University of London North Mymms Hertfordshire UK
| | - Thomas Greensmith
- Department of Clinical Science and Services The Royal Veterinary College University of London North Mymms Hertfordshire UK
| | - Laura Cole
- Department of Clinical Science and Services The Royal Veterinary College University of London North Mymms Hertfordshire UK
| | - Stefano Cortellini
- Department of Clinical Science and Services The Royal Veterinary College University of London North Mymms Hertfordshire UK
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6
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Bode MJ, Huber J, Roberts DM. Decision-making in suicide: When is the patient not for resuscitation? Emerg Med Australas 2022; 34:473-474. [PMID: 35384301 DOI: 10.1111/1742-6723.13977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Matthew Jf Bode
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,Department of Emergency Medicine, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Jacqueline Huber
- Department of Psychiatry, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,St Vincent's Clinical School, The University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,St Vincent's Clinical School, The University of New South Wales, Darlinghurst, New South Wales, Australia.,Drug Health, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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7
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Harbell MW, Dumitrascu C, Bettini L, Yu S, Thiele CM, Koyyalamudi V. Anesthetic Considerations for Patients on Psychotropic Drug Therapies. Neurol Int 2021; 13:640-658. [PMID: 34940748 PMCID: PMC8708655 DOI: 10.3390/neurolint13040062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 11/08/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022] Open
Abstract
Psychotropic drugs are used in the treatment of psychiatric and non-psychiatric conditions. Many patients who are on psychotropic medications may present for procedures requiring anesthesia. Psychotropic medications can have dangerous interactions with drugs commonly used in anesthesia, some of which can be life-threatening. In this review, we describe the current anesthetic considerations for patients on psychotropic drug therapies, including antidepressants, antipsychotics, mood stabilizers, anxiolytics, and stimulants. The pharmacology, side effects, and potential drug interactions of the commonly prescribed psychotropic drug therapies with anesthetic agents are described. Further, we highlight the current recommendations regarding the cessation and continuation of these medications during the perioperative period.
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Affiliation(s)
- Monica W. Harbell
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; (C.D.); (L.B.); (S.Y.); (V.K.)
- Correspondence:
| | - Catalina Dumitrascu
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; (C.D.); (L.B.); (S.Y.); (V.K.)
| | - Layne Bettini
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; (C.D.); (L.B.); (S.Y.); (V.K.)
| | - Soojie Yu
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; (C.D.); (L.B.); (S.Y.); (V.K.)
| | | | - Veerandra Koyyalamudi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; (C.D.); (L.B.); (S.Y.); (V.K.)
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8
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Jiranantakan T, Ritchie S, Rowe C, Tran J, McDonald C, Vazquez S, Auld R, Brown J. Retracted: Survival After Pentobarbitone Overdose Confirmed Through Prescription, Recreational and Illicit Substance Evaluation (Prise) Programme in Australia. Forensic Sci Res 2021; 6:231-236. [PMID: 34868716 PMCID: PMC8635673 DOI: 10.1080/20961790.2021.1975613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Thanjira Jiranantakan
- Centre for Alcohol and Other Drugs, NSW Ministry of
Health, St Leonards, Australia
- NSW Poisons Information Centre, The Sydney Children’s
Hospitals Network, Westmead,
Australia
- Edith Collins Centre, Central Clinical School, Faculty of
Medicine and Health, The University of Sydney,
Sydney, Australia
- Drug Health Services, Royal Prince Alfred
Hospital, Camperdown, Australia
| | | | - Cristy Rowe
- Wagga Wagga Base Hospital, Wagga
Wagga, Australia
| | - Jason Tran
- Forensic Toxicology, NSW Health Pathology, Forensic &
Analytical Science Service,
Lidcombe, Australia
| | - Catherine McDonald
- Forensic Toxicology, NSW Health Pathology, Forensic &
Analytical Science Service,
Lidcombe, Australia
| | - Santiago Vazquez
- Forensic Toxicology, NSW Health Pathology, Forensic &
Analytical Science Service,
Lidcombe, Australia
| | - Robin Auld
- Centre for Alcohol and Other Drugs, NSW Ministry of
Health, St Leonards, Australia
| | - Jared Brown
- Centre for Alcohol and Other Drugs, NSW Ministry of
Health, St Leonards, Australia
- NSW Poisons Information Centre, The Sydney Children’s
Hospitals Network, Westmead,
Australia
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9
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Doyno CR, White CM. Sedative-Hypnotic Agents That Impact Gamma-Aminobutyric Acid Receptors: Focus on Flunitrazepam, Gamma-Hydroxybutyric Acid, Phenibut, and Selank. J Clin Pharmacol 2021; 61 Suppl 2:S114-S128. [PMID: 34396551 DOI: 10.1002/jcph.1922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 06/03/2021] [Indexed: 12/29/2022]
Abstract
There are many nonopioid central nervous system depressant substances that share a gamma-aminobutyric acid (GABA) receptor-related mechanism of action. These sedatives-hypnotics can be indicated to treat anxiety, seizures, depression, and insomnia but are also used as substances of abuse and used to facilitate sexual assault. Barbiturates, methaqualone, and glutethimide were among the first type A GABA receptor-mediated sedative-hypnotics. Their clinical use was limited for most indications by serious adverse events and strong abuse potential but continue to be used illicitly around the world. The benzodiazepines supplanted barbiturates for most indications because they were less likely to cause severe adverse events in monotherapy. Flunitrazepam is a newer benzodiazepine that is preferentially used recreationally and to facilitate sexual assault. Flunitrazepam has greater potency and higher affinity for the type A GABA receptor than most benzodiazepines. Gamma-hydroxybutyric acid is sought illicitly for its hypnotic, euphoric and anabolic effects as well as to facilitate sexual assault. When any of these GABAergic drugs are used in high doses or with other sedative hypnotic agents, respiratory depression, coma, and death have occurred. Chronic use of these GABAergic drugs can lead to significant withdrawal syndromes. Phenibut and selank are poorly studied Russian drugs with GABAergic mechanisms that are inexplicably sold to US consumers as dietary supplements. Poison control center calls regarding phenibut have increased substantially over the past 5 years. Desired euphoriant effects account for the recreational and illicit use of many GABA-modulating agents. However, illicit use can lead to significant toxicities related to abuse, dependence, and subsequent withdrawal syndromes. Significant evaluation of developing agents with GABA properties should be conducted to determine abuse potential before public access ensues.
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Affiliation(s)
- Cassandra R Doyno
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA.,John Dempsey Hospital, University of Connecticut, Farmington, Connecticut, USA
| | - C Michael White
- Department of Research Administration, Hartford Hospital, Hartford, Connecticut, USA
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10
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Minissale MG, Giannitrapani L, Capitano A, Morreale I, Licata A. A questionable diagnosis in a woman with drowsiness. Intern Emerg Med 2021; 16:1017-1021. [PMID: 31848993 DOI: 10.1007/s11739-019-02256-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Maria Giovanna Minissale
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica "G. D'Alessandro", PROMISE, University of Palermo, Via del Vespro 141, 90127, Palermo, Italy.
| | - Lidya Giannitrapani
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica "G. D'Alessandro", PROMISE, University of Palermo, Via del Vespro 141, 90127, Palermo, Italy
| | - Adele Capitano
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica "G. D'Alessandro", PROMISE, University of Palermo, Via del Vespro 141, 90127, Palermo, Italy
| | - Ilaria Morreale
- Unità di Farmacologia Clinica, Centro di Riferimento Siciliano per la Farmacovigilanza, AOUP P. Giaccone, Università di Palermo, Palermo, Italy
| | - Anna Licata
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica "G. D'Alessandro", PROMISE, University of Palermo, Via del Vespro 141, 90127, Palermo, Italy
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11
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Affiliation(s)
- David C Sheridan
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Adrienne Hughes
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.,Oregon Poison Center, Portland, OR
| | - B Zane Horowitz
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.,Oregon Poison Center, Portland, OR
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12
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Katz KD, Koons A, Makar G, Wier A. Old and Cold: A Novel Case of Combined Secobarbital and Pentobarbital Poisoning in an Elderly Woman. Cureus 2021; 13:e12446. [PMID: 33552764 PMCID: PMC7854340 DOI: 10.7759/cureus.12446] [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: 11/15/2022] Open
Abstract
A 94-year-old woman was found unresponsive in her room at an independent living facility. Upon paramedic arrival, the patient had a Glasgow Coma Scale of 3, and she was transported to the emergency department (ED). In the ED, she was unresponsive but spontaneously breathing, bradycardia, and hypothermia. Serum concentrations of both secobarbital (3.3µg/mL; therapeutic 1.0-2.0µg/mL) and pentobarbital (9.5µg/mL; therapeutic < 5.0µg/mL) were detected and elevated. This type of poisoning is quite rare and should be considered in patients presenting with hypothermia and coma, even in patients showing brain death signs. The use of hemodialysis for refractory pentobarbital poisoning may be helpful.
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Affiliation(s)
- Kenneth D Katz
- Emergency Medicine • Medical Toxicology, University of South Florida Morsani College of Medicine / Lehigh Valley Health Network, Allentown, USA
| | - Andrew Koons
- Emergency Medicine • Medical Toxicology, University of South Florida Morsani College of Medicine / Lehigh Valley Health Network, Allentown, USA
| | - Gregory Makar
- Emergency Medicine, University of South Florida Morsani College of Medicine / Lehigh Valley Health Network, Allentown, USA
| | - Amy Wier
- Emergency Medicine, University of South Florida Morsani College of Medicine / Lehigh Valley Health Network, Allentown, USA
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13
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Mizushima S, Hirose Y, Yuzawa H, Kimura T, Oguchi M, Morito T, Sadahiro T. Efficacy of direct hemoperfusion for the removal of phenobarbital through blood concentration analysis. Acute Med Surg 2020; 7:e601. [PMID: 33235801 PMCID: PMC7671091 DOI: 10.1002/ams2.601] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/22/2020] [Indexed: 11/11/2022] Open
Abstract
Aim Phenobarbital overdose can cause coma and even death. The consciousness disturbance is often prolonged due to its long half-life. In this study, we investigated the efficacy of direct hemoperfusion (DHP) for the removal of phenobarbital by measuring the blood levels of phenobarbital. Methods Study subjects included five patients with phenobarbital poisoning who were transferred to our hospital. Direct hemoperfusion was carried out in three of the five patients (six times in total), and the elimination rate was calculated by measuring the blood levels before and after DHP. Furthermore, the disappearance rate of phenobarbital without DHP was calculated in all five patients (seven times in total) for comparison with the elimination rate. Results The elimination rate of phenobarbital with DHP was significantly higher than the disappearance rate without DHP.. Conclusion This study suggests that early introduction of DHP should be considered as a treatment option for phenobarbital poisoning.
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Affiliation(s)
- Shohei Mizushima
- Department of Emergency and Critical Care Medicine Tokyo Women's Medical University Yachiyo Medical Center Chiba Japan
| | - Yousuke Hirose
- Department of Emergency and Critical Care Medicine Tokyo Women's Medical University Yachiyo Medical Center Chiba Japan
| | - Hiroko Yuzawa
- Department of Emergency and Critical Care Medicine Tokyo Women's Medical University Yachiyo Medical Center Chiba Japan
| | - Tomonori Kimura
- Department of Emergency and Critical Care Medicine Tokyo Women's Medical University Yachiyo Medical Center Chiba Japan
| | - Moe Oguchi
- Department of Emergency and Critical Care Medicine Tokyo Women's Medical University Yachiyo Medical Center Chiba Japan
| | - Tomohiro Morito
- Department of Emergency and Critical Care Medicine Tokyo Women's Medical University Yachiyo Medical Center Chiba Japan
| | - Tomohito Sadahiro
- Department of Emergency and Critical Care Medicine Tokyo Women's Medical University Yachiyo Medical Center Chiba Japan
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14
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Ammar MA, Ammar AA, Rosen J, Kassab HS, Becher RD. Phenobarbital Monotherapy for the Management of Alcohol Withdrawal Syndrome in Surgical-Trauma Patients. Ann Pharmacother 2020; 55:294-302. [PMID: 32830517 DOI: 10.1177/1060028020949137] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Benzodiazepine is first-line therapy for alcohol withdrawal syndrome (AWS), and phenobarbital is an alternative therapy. However, its use has not been well validated in the surgical-trauma patient population. OBJECTIVE To describe the use of fixed-dose phenobarbital monotherapy for the management of patients at risk for AWS in the surgical-trauma intensive care unit. METHODS Surgical-trauma critically ill patients who received phenobarbital monotherapy, loading dose followed by a taper regimen, for the management of AWS were included in this evaluation. The effectiveness of phenobarbital monotherapy to treat AWS and prevent development of AWS-related complications were evaluated. Safety end points assessed included significant hypotension, bradycardia, respiratory depression, and need for invasive mechanical ventilation. RESULTS A total of 31 patients received phenobarbital monotherapy; the majority of patients were at moderate risk for developing AWS (n = 20; 65%) versus high risk (n = 11; 35%). None of the patients developed AWS-related complications; all patients were successfully managed for their AWS. Nine patients (29%) received nonbenzodiazepine adjunct therapy for agitation post-phenobarbital initiation. Three patients (10%) experienced hypotension, and 3 (10%) were intubated. None of the patients had clinically significant bradycardia or respiratory depression. CONCLUSION AND RELEVANCE Fixed-dose phenobarbital monotherapy appears to be well tolerated and effective in the management of AWS. Further evaluation is needed to determine the extent of benefit with the use of phenobarbital monotherapy for management of AWS.
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15
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Campbell G, Darke S, Zahra E, Duflou J, Shand F, Lappin J. Trends and characteristics in barbiturate deaths Australia 2000–2019: a national retrospective study. Clin Toxicol (Phila) 2020; 59:224-230. [DOI: 10.1080/15563650.2020.1789653] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- G. Campbell
- School of Health and Sport Sciences, University of the Sunshine Coast, Sunshine Coast, Australia
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - S. Darke
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - E. Zahra
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - J. Duflou
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - F. Shand
- Black Dog Institute, UNSW Sydney, Sydney, Australia
| | - J. Lappin
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
- School of Psychiatry, UNSW Sydney, Sydney, Australia
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16
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Dexmedetomidine versus other sedatives for non-painful pediatric examinations: A systematic review and meta-analysis of randomized controlled trials. J Clin Anesth 2020; 62:109736. [DOI: 10.1016/j.jclinane.2020.109736] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/20/2019] [Accepted: 01/25/2020] [Indexed: 01/04/2023]
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17
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Basile JK, Vigani A. Treatment of phenobarbital intoxication using hemodialysis in two dogs. J Vet Emerg Crit Care (San Antonio) 2020; 30:221-225. [PMID: 31975513 DOI: 10.1111/vec.12908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 02/21/2018] [Accepted: 03/22/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To describe the use of hemodialysis in 2 dogs with severe clinical signs from phenobarbital intoxication. SERIES SUMMARY Two dogs ingested a toxic dose of phenobarbital, leading to severe neurological dysfunction and a comatose state. Both dogs received a 3-hour session of hemodialysis with complete resolution of clinical signs and returned to normal mentation by the end of the therapy. No negative side effects occurred and phenobarbital concentrations returned to therapeutic range during treatment. NEW INFORMATION PROVIDED This is the first report on the utility and safety of using hemodialysis for phenobarbital intoxication in dogs.
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Affiliation(s)
- Jessica Kielb Basile
- Emergency and Critical Care Service, North Carolina State Veterinary Hospital, Raleigh, NC
| | - Alessio Vigani
- Emergency and Critical Care Service, North Carolina State Veterinary Hospital, Raleigh, NC
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18
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Wen D, Shi Y, Zhang X, Xie B, Liu W, Yu F, Xiang P, Cong B, Ma C. Determination of barbiturates in hair samples by using a validated UHPLC-HRMS method: application in investigation of drug-facilitated sexual assault. Forensic Sci Res 2019; 7:78-87. [PMID: 35341124 PMCID: PMC8942540 DOI: 10.1080/20961790.2019.1659474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Affiliation(s)
- Di Wen
- College of Forensic Medicine, Hebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, Shijiazhuang, China
| | - Yan Shi
- Academy of Forensic Science, Ministry of Justice, Shanghai Key Laboratory of Forensic Medicine, Shanghai, China
| | - Xiaoguang Zhang
- Core Facility of Hebei Medical University, Shijiazhuang, China
| | - Bing Xie
- College of Forensic Medicine, Hebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, Shijiazhuang, China
| | - Wenqiao Liu
- College of Forensic Medicine, Hebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, Shijiazhuang, China
| | - Feng Yu
- College of Forensic Medicine, Hebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, Shijiazhuang, China
| | - Ping Xiang
- Academy of Forensic Science, Ministry of Justice, Shanghai Key Laboratory of Forensic Medicine, Shanghai, China
| | - Bin Cong
- College of Forensic Medicine, Hebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, Shijiazhuang, China
| | - Chunling Ma
- College of Forensic Medicine, Hebei Medical University, Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, Shijiazhuang, China
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Revisiting clinical practice in therapeutic drug monitoring of first-generation antiepileptic drugs. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00662-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Avau B, Borra V, Vanhove A, Vandekerckhove P, De Paepe P, De Buck E. First aid interventions by laypeople for acute oral poisoning. Cochrane Database Syst Rev 2018; 12:CD013230. [PMID: 30565220 PMCID: PMC6438817 DOI: 10.1002/14651858.cd013230] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Oral poisoning is a major cause of mortality and disability worldwide, with estimates of over 100,000 deaths due to unintentional poisoning each year and an overrepresentation of children below five years of age. Any effective intervention that laypeople can apply to limit or delay uptake or to evacuate, dilute or neutralize the poison before professional help arrives may limit toxicity and save lives. OBJECTIVES To assess the effects of pre-hospital interventions (alone or in combination) for treating acute oral poisoning, available to and feasible for laypeople before the arrival of professional help. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, ISI Web of Science, International Pharmaceutical Abstracts, and three clinical trials registries to 11 May 2017, and we also carried out reference checking and citation searching. SELECTION CRITERIA We included randomized controlled trials comparing interventions (alone or in combination) that are feasible in a pre-hospital setting for treating acute oral poisoning patients, including but potentially not limited to activated charcoal (AC), emetics, cathartics, diluents, neutralizing agents and body positioning. DATA COLLECTION AND ANALYSIS Two reviewers independently performed study selection, data collection and assessment. Primary outcomes of this review were incidence of mortality and adverse events, plus incidence and severity of symptoms of poisoning. Secondary outcomes were duration of symptoms of poisoning, drug absorption, and incidence of hospitalization and ICU admission. MAIN RESULTS We included 24 trials involving 7099 participants. Using the Cochrane 'Risk of bias' tool, we assessed no study as being at low risk of bias for all domains. Many studies were poorly reported, so the risk of selection and detection biases were often unclear. Most studies reported important outcomes incompletely, and we judged them to be at high risk of reporting bias.All but one study enrolled oral poisoning patients in an emergency department; the remaining study was conducted in a pre-hospital setting. Fourteen studies included multiple toxic syndromes or did not specify, while the other studies specifically investigated paracetamol (2 studies), carbamazepine (2 studies), tricyclic antidepressant (2 studies), yellow oleander (2 studies), benzodiazepine (1 study), or toxic berry intoxication (1 study). Eighteen trials investigated the effects of activated charcoal (AC), administered as a single dose (SDAC) or in multiple doses (MDAC), alone or in combination with other first aid interventions (a cathartic) and/or hospital treatments. Six studies investigated syrup of ipecac plus other first aid interventions (SDAC + cathartic) versus ipecac alone. The collected evidence was mostly of low to very low certainty, often downgraded for indirectness, risk of bias or imprecision due to low numbers of events.First aid interventions that limit or delay the absorption of the poison in the bodyWe are uncertain about the effect of SDAC compared to no intervention on the incidence of adverse events in general (zero events in both treatment groups; 1 study, 451 participants) or vomiting specifically (Peto odds ratio (OR) 4.17, 95% confidence interval (CI) 0.30 to 57.26, 1 study, 25 participants), ICU admission (Peto OR 7.77, 95% CI 0.15 to 391.93, 1 study, 451 participants) and clinical deterioration (zero events in both treatment groups; 1 study, 451 participants) in participants with mixed types or paracetamol poisoning, as all evidence for these outcomes was of very low certainty. No studies assessed SDAC for mortality, duration of symptoms, drug absorption or hospitalization.Only one study compared SDAC to syrup of ipecac in participants with mixed types of poisoning, providing very low-certainty evidence. Therefore we are uncertain about the effects on Glasgow Coma Scale scores (mean difference (MD) -0.15, 95% CI -0.43 to 0.13, 1 study, 34 participants) or incidence of adverse events (risk ratio (RR) 1.24, 95% CI 0.26 to 5.83, 1 study, 34 participants). No information was available concerning mortality, duration of symptoms, drug absorption, hospitalization or ICU admission.This review also considered the added value of SDAC or MDAC to hospital interventions, which mostly included gastric lavage. No included studies investigated the use of body positioning in oral poisoning patients.First aid interventions that evacuate the poison from the gastrointestinal tractWe found one study comparing ipecac versus no intervention in toxic berry ingestion in a pre-hospital setting. Low-certainty evidence suggests there may be an increase in the incidence of adverse events, but the study did not report incidence of mortality, incidence or duration of symptoms of poisoning, drug absorption, hospitalization or ICU admission (103 participants).In addition, we also considered the added value of syrup of ipecac to SDAC plus a cathartic and the added value of a cathartic to SDAC.No studies used cathartics as an individual intervention.First aid interventions that neutralize or dilute the poison No included studies investigated the neutralization or dilution of the poison in oral poisoning patients.The review also considered combinations of different first aid interventions. AUTHORS' CONCLUSIONS The studies included in this review provided mostly low- or very low-certainty evidence about the use of first aid interventions for acute oral poisoning. A key limitation was the fact that only one included study actually took place in a pre-hospital setting, which undermines our confidence in the applicability of these results to this setting. Thus, the amount of evidence collected was insufficient to draw any conclusions.
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Affiliation(s)
- Bert Avau
- Belgian Red CrossCentre for Evidence‐Based PracticeMotstraat 42MechelenBelgium2800
- Belgian Centre for Evidence‐Based Medicine ‐ Cochrane BelgiumKapucijnenvoer 33, blok JLeuvenBelgium3000
| | - Vere Borra
- Belgian Red CrossCentre for Evidence‐Based PracticeMotstraat 42MechelenBelgium2800
| | - Anne‐Catherine Vanhove
- Belgian Red CrossCentre for Evidence‐Based PracticeMotstraat 42MechelenBelgium2800
- Belgian Centre for Evidence‐Based Medicine ‐ Cochrane BelgiumKapucijnenvoer 33, blok JLeuvenBelgium3000
| | - Philippe Vandekerckhove
- Belgian Red CrossMotstraat 40MechelenBelgium2800
- KU LeuvenDepartment of Public Health and Primary Care, Faculty of MedicineKapucijnenvoer 35 blok dLeuvenBelgium3000
| | - Peter De Paepe
- Ghent University HospitalDepartment of Emergency MedicineGhentBelgium
| | - Emmy De Buck
- Belgian Red CrossCentre for Evidence‐Based PracticeMotstraat 42MechelenBelgium2800
- KU LeuvenDepartment of Public Health and Primary Care, Faculty of MedicineKapucijnenvoer 35 blok dLeuvenBelgium3000
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21
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Druda DF, Gone S, Graudins A. Deliberate Self-poisoning with a Lethal Dose of Pentobarbital with Confirmatory Serum Drug Concentrations: Survival After Cardiac Arrest with Supportive Care. J Med Toxicol 2018; 15:45-48. [PMID: 30073621 DOI: 10.1007/s13181-018-0675-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/28/2018] [Accepted: 07/06/2018] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Pentobarbital (PB) is a euthanasia drug in doses of 2 to 10 grams, causing death within 15-30 minutes. We report a case of recovery from lethal pentobarbital deliberate self-poisoning with confirmatory serum drug concentrations. CASE REPORT A 45-year-old male purchased 20 grams of PB powder over the Internet. He ingested this powder and then alerted his mother 10 minutes later. She found him unresponsive and commenced cardiopulmonary resuscitation (CPR). Within 20 minutes of ingestion, emergency medical services arrived and initiated advanced life support. On arrival to the emergency department, heart rate was 116 bpm, BP 117/62 mmHg, on an epinephrine infusion. He was hypotonic and hypothermic, with absent brainstem reflexes. ECG and CT brain were normal. Activated charcoal was administered and he was admitted to ICU. He remained comatose with absent brainstem reflexes until day 5. Cerebral angiogram on day 3 was normal. Qualitative urine testing detected pentobarbital suggesting ongoing drug effects as the cause of coma. He was extubated on day 10, eventually making a full recovery. At 2.5 hours post-ingestion, PB concentration was 112 mg/L; PB peaked at 116 mg/L at 29 hours; PB was 2 mg/L at 190 hours and undetectable over 200 hours post-ingestion. DISCUSSION Average PB concentration in fatalities is reported around 30 mg/L. This patient survived higher serum concentrations with early CPR and prolonged cardiorespiratory support in the ICU. Assessment of brainstem death should be deferred until PB has been adequately eliminated.
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Affiliation(s)
- Dino F Druda
- Monash Health Clinical Toxicology Unit and Monash Emergency Medicine Service, Monash Health, Melbourne, Australia.
- Department of Emergency Medicine, Dandenong Hospital, David Street, Dandenong, Victoria, 3175, Australia.
| | - Santosh Gone
- Monash Health Clinical Toxicology Unit and Monash Emergency Medicine Service, Monash Health, Melbourne, Australia
| | - Andis Graudins
- Monash Health Clinical Toxicology Unit and Monash Emergency Medicine Service, Monash Health, Melbourne, Australia
- Department of Emergency Medicine, Dandenong Hospital, David Street, Dandenong, Victoria, 3175, Australia
- Monash Emergency Research Collaborative, Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Le Page AK, Stewart AE, Roehr CC, Johnstone LM, Graudins A. The Use of Peritoneal Dialysis in Phenobarbitone Toxicity in a Critically Unwell Neonate. Neonatology 2018; 113:117-121. [PMID: 29169160 DOI: 10.1159/000481879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 10/02/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Phenobarbitone (PB) is the first-line anti-convulsant for neonatal seizures. The use of peritoneal dialysis (PD) to enhance drug elimination in cases of neonatal PB overdose has not been reported. OBJECTIVE To report a case of neonatal severe PB toxicity and review the elimination of PB by PD. METHODS Assessment of PD drug clearance. RESULTS A neonate with prolonged seizures was administered PB. Encephalopathy and myocardial failure developed, which were initially suspected to be secondary to hypoxia. At 42 h of age, the serum PB concentration was in the toxic range at 131 mg/L. Despite supportive care, the infant's condition deteriorated with escalating inotropes and the need for CPR. Enhanced PB elimination via multiple-dose activated charcoal and exchange transfusion were considered too risky. Hourly PD cycles via Tenckhoff catheter were commenced, based on reports suggesting that PD enhances PB clearance. The clinical state of the infant then improved. PD administration was continued for 60 h, recovering 20% of the estimated total PB body load. The infant survived and there were no PD complications. CONCLUSIONS PD increased PB clearance in this neonate, correlating with clinical recovery. Where other techniques are not possible, PD may have a role to play in enhancing PB elimination.
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Affiliation(s)
- Amelia K Le Page
- Department of Nephrology, Monash Children's Hospital, Clayton, VIC, Australia
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23
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Hensler DM, McConnell DP, Levasseur-Franklin KE, Greathouse KM. Pentobarbital Removal During Continuous Venovenous Hemofiltration: Case Report and Review of the Literature. J Pharm Pract 2017; 31:682-686. [PMID: 29162023 DOI: 10.1177/0897190017743130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND: Renal replacement therapy may enhance the elimination of barbiturates. Pentobarbital clearance during continuous venovenous hemofiltration (CVVH) has not been described previously. We report a patient case involving the measurement of serial pentobarbital levels during CVVH and review relevant literature characterizing extracorporeal pentobarbital elimination. METHODS: The following is a retrospective report of a previously healthy 26-year-old woman who sustained a severe traumatic brain injury (TBI) and required administration of pentobarbital on hospital day 0 for intracranial pressure (ICP) control. Given concern for interference with the patient's ongoing neurologic assessments, pentobarbital was discontinued on hospital day 4. The patient's hospital course was complicated by acute kidney injury (AKI), requiring initiation of CVVH on hospital day 5. Daily serum pentobarbital levels were obtained during CVVH. RESULTS: While on CVVH, the patient's estimated pentobarbital clearance ranged from 6 to 44 mL/min and the elimination half-life ranged from 17.7 to 65.9 hours. Based on reductions in pentobarbital clearance during CVVH interruption, the elimination of drug was dependent upon extracorporeal removal in this patient. CVVH facilitated pentobarbital elimination in a manner approaching endogenous clearance in healthy individuals. CONCLUSION: We report clinically significant pentobarbital removal by CVVH in a patient with severe TBI. Application of CVVH may expedite reliable neurologic assessments and facilitate the application of clinical brain death examination following pentobarbital exposure.
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Affiliation(s)
- David M Hensler
- 1 Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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24
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Kıhtır HS, Yıldırım HM, Yeşilbaş O, Duramaz BB, Şevketoğlu E. Single-pass albumin dialysis in a child aged six months with phenobarbital poisoning. Turk Arch Pediatr 2016; 51:228-230. [PMID: 28123338 DOI: 10.5152/turkpediatriars.2016.2335] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 04/07/2015] [Indexed: 11/22/2022]
Abstract
A girl aged six months was hospitalized because of resistant seizures and was discharged with phenobarbital and carbamazepine therapy. She was admitted to a state hospital with symptoms of inability to waken and difficulty in breathing. It was learned that phenobarbital had been used incorrectly and the patient was sent to our pediatric intensive care unit because of severe phenobarbital overdose. The decision was taken for hemodialysis. Single-pass albumin dialysis was planned because phenobarbital can bind to high levels of plasma protein. The process was undertaken with 1% albumin-containing dialysate, which was prepared manually. After 6 hours of dialysis, the phenobarbital blood level measured 62 mcg/mL (>140 mcg/mL on admission) and the patient's clinical findings were markedly regressed. There are no case reports about phenobarbital overdose treated with single-pass albumin dialysis in the literature. We conclude that single-pass albumin dialysis may be a useful treatment, especially with intoxications of drugs that bind protein at high levels.
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Affiliation(s)
- Hasan Serdar Kıhtır
- Clinic of Pediatrics, Division of Pediatric Intensive Care, Bakırköy Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Hamdi Murat Yıldırım
- Clinic of Pediatrics, Division of Pediatric Intensive Care, Bakırköy Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Osman Yeşilbaş
- Clinic of Pediatrics, Division of Pediatric Intensive Care, Bakırköy Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Burcu Bursal Duramaz
- Clinic of Pediatrics, Bakırköy Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Esra Şevketoğlu
- Clinic of Pediatrics, Division of Pediatric Intensive Care, Bakırköy Sadi Konuk Training and Research Hospital, İstanbul, Turkey
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Baarslag MA, Allegaert K, Knibbe CAJ, van Dijk M, Tibboel D. Pharmacological sedation management in the paediatric intensive care unit. J Pharm Pharmacol 2016; 69:498-513. [DOI: 10.1111/jphp.12630] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
Abstract
Objective
This review addresses sedation management on paediatric intensive care units and possible gaps in the knowledge of optimal sedation strategies. We present an overview of the commonly used sedatives and their pharmacokinetic and pharmacodynamic considerations in children, as well as the ongoing studies in this field. Also, sedation guidelines and current sedation strategies and assessment methods are addressed.
Key findings
This review shows that evidence and pharmacokinetic data are scarce, but fortunately, there is an active research scene with promising new PK and PD data of sedatives in children using new study designs with application of advanced laboratory methods and modelling. The lack of evidence is increasingly being recognized by authorities and legislative offices such as the US Food and Drug Administration (FDA) and European Medicines Agency (EMA).
Conclusion
The population in question is very heterogeneous and this overview can aid clinicians and researchers in moving from practice-based sedation management towards more evidence- or model-based practice. Still, paediatric sedation management can be improved in other ways than pharmacology only, so future research should aim on sedation assessment and implementation strategies of protocolized sedation as well.
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Affiliation(s)
- Manuel A Baarslag
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of development and regeneration, KU Leuven, Belgium
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - Monique van Dijk
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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26
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Roveri FL, Paranhos BAPB, Yonamine M. Determination of phenobarbital in hair matrix by liquid phase microextraction (LPME) and gas chromatography–mass spectrometry (GC–MS). Forensic Sci Int 2016; 265:75-80. [DOI: 10.1016/j.forsciint.2015.12.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/15/2015] [Accepted: 12/26/2015] [Indexed: 10/22/2022]
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Southerland JH, Brown LR. Conscious Intravenous Sedation in Dentistry: A Review of Current Therapy. Dent Clin North Am 2016; 60:309-346. [PMID: 27040288 DOI: 10.1016/j.cden.2015.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Several sedation options are used to minimize pain, anxiety, and discomfort during oral surgery procedures. Minimizing or eliminating pain and anxiety for dental care is the primary goal for conscious sedation. Intravenous conscious sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate as well as cardiovascular function. Patients must retain their protective airway reflexes, and respond to and understand verbal communication. The drugs and techniques used must therefore carry a broad margin of safety.
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Affiliation(s)
- Janet H Southerland
- Department of Oral and Maxillofacial Surgery, Meharry Medical College School of Dentistry, 1005 Dr. DB Todd Jr. Boulevard, Nashville, TN 37208, USA.
| | - Lawrence R Brown
- Dadeland Oral Surgery Associates, 8950 S.W. 74th Court, Suite 1610, Miami Florida 33156; Baptist Hospital Of Miami, 8900 North Kendall Drive, Miami Florida 33176
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Mut L, Grobosch T, Binscheck-Domaß T, Frenzel W. Toxicological screening of human plasma by on-line SPE-HPLC-DAD: identification and quantification of acidic and neutral drugs. Biomed Chromatogr 2015; 30:343-62. [DOI: 10.1002/bmc.3554] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 06/02/2015] [Accepted: 07/02/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Ludmila Mut
- Berlin Institute of Technology; Department of Environmental Technology; Straße des 17. Juni 135 D-10623 Berlin Germany
| | - Thomas Grobosch
- Labor Berlin - Charité Vivantes GmbH; Department for Laboratory Medicine and Toxicology; Sylter Str. 2 D-13353 Berlin Germany
| | - Torsten Binscheck-Domaß
- Labor Berlin - Charité Vivantes GmbH; Department for Laboratory Medicine and Toxicology; Sylter Str. 2 D-13353 Berlin Germany
| | - Wolfgang Frenzel
- Berlin Institute of Technology; Department of Environmental Technology; Straße des 17. Juni 135 D-10623 Berlin Germany
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Ruhe M, Grautoff S, Kähler J, Pohle T. [Suicide attempt by means of phenobarbital overdose. Effective treatment with continuous veno-venous hemodialysis]. Med Klin Intensivmed Notfmed 2015; 111:141-4. [PMID: 26070921 DOI: 10.1007/s00063-015-0046-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/01/2015] [Accepted: 04/08/2015] [Indexed: 10/23/2022]
Abstract
A 68-year-old woman tried to commit suicide using phenobarbital, which was initially prescribed for her dog that suffered from seizures. At admission she was unconscious and ventilated. Five days of intensive care therapy did not improve her state of consciousness. Subsequent continuous veno-venous hemodialysis accelerated the elimination of phenobarbital compared to endogenous elimination by a factor of five. The patient survived without sequelae. Detailed history taking and well-timed indication for dialysis were crucial.
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Affiliation(s)
- M Ruhe
- Medizinische Klinik I, Klinikum Herford, Schwarzenmoorstraße 70, 32049, Herford, Deutschland.
| | - S Grautoff
- Medizinische Klinik III, Klinikum Herford, Schwarzenmoorstraße 70, 32049, Herford, Deutschland
| | - J Kähler
- Medizinische Klinik III, Klinikum Herford, Schwarzenmoorstraße 70, 32049, Herford, Deutschland
| | - T Pohle
- Medizinische Klinik I, Klinikum Herford, Schwarzenmoorstraße 70, 32049, Herford, Deutschland
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Mactier R, Laliberté M, Mardini J, Ghannoum M, Lavergne V, Gosselin S, Hoffman RS, Nolin TD. Extracorporeal treatment for barbiturate poisoning: recommendations from the EXTRIP Workgroup. Am J Kidney Dis 2014; 64:347-58. [PMID: 24998037 DOI: 10.1053/j.ajkd.2014.04.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 04/07/2014] [Indexed: 11/11/2022]
Abstract
The EXTRIP (Extracorporeal Treatments in Poisoning) Workgroup conducted a systematic review of barbiturate poisoning using a standardized evidence-based process to provide recommendations on the use of extracorporeal treatment (ECTR) in patients with barbiturate poisoning. The authors reviewed all articles, extracted data, summarized key findings, and proposed structured voting statements following a predetermined format. A 2-round modified Delphi method was used to reach a consensus on voting statements, and the RAND/UCLA Appropriateness Method was used to quantify disagreement. 617 articles met the search inclusion criteria. Data for 538 patients were abstracted and evaluated. Only case reports, case series, and nonrandomized observational studies were identified, yielding a low quality of evidence for all recommendations. Using established criteria, the workgroup deemed that long-acting barbiturates are dialyzable and short-acting barbiturates are moderately dialyzable. Four key recommendations were made. (1) The use of ECTR should be restricted to cases of severe long-acting barbiturate poisoning. (2) The indications for ECTR in this setting are the presence of prolonged coma, respiratory depression necessitating mechanical ventilation, shock, persistent toxicity, or increasing or persistently elevated serum barbiturate concentrations despite treatment with multiple-dose activated charcoal. (3) Intermittent hemodialysis is the preferred mode of ECTR, and multiple-dose activated charcoal treatment should be continued during ECTR. (4) Cessation of ECTR is indicated when clinical improvement is apparent. This report provides detailed descriptions of the rationale for all recommendations. In summary, patients with long-acting barbiturate poisoning should be treated with ECTR provided at least one of the specific criteria in the first recommendation is present.
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Affiliation(s)
- Robert Mactier
- Renal Services, NHS Greater Glasgow & Clyde, Glasgow, Scotland, United Kingdom
| | - Martin Laliberté
- Department of Emergency Medicine, McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Joelle Mardini
- Department of Nephrology, Verdun Hospital, University of Montreal, Verdun, QC, Canada
| | - Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montreal, Verdun, QC, Canada
| | - Valery Lavergne
- Department of Medical Biology, Sacre-Coeur Hospital, University of Montreal, QC, Canada
| | - Sophie Gosselin
- Department of Emergency Medicine, Medical Toxicology Service, McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Robert S Hoffman
- Division of Medical Toxicology, Department of Medicine, New York University School of Medicine, New York, NY; Department of Emergency Medicine, New York University School of Medicine, New York, NY
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA; Department of Medicine, Renal Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA.
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Ghannoum M, Roberts DM, Hoffman RS, Ouellet G, Roy L, Decker BS, Bouchard J. A stepwise approach for the management of poisoning with extracorporeal treatments. Semin Dial 2014; 27:362-70. [PMID: 24697864 DOI: 10.1111/sdi.12228] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of an extracorporeal treatment (ECTR) in a poisoned patient may be life-saving in a limited number of scenarios. The decision-processes surrounding the use of ECTR in poisoning is complex: most nephrologists are not trained to assess a poisoned patient while clinical toxicologists rarely prescribe ECTRs. Deciding on which ECTR is most appropriate for a poison requires a good understanding of the poison's physicochemical and pharmacokinetic properties. Further, a detailed understanding of the capabilities and limitations of the different ECTRs can be useful to select the most appropriate ECTR for a given clinical situation. This manuscript provides a stepwise approach to assess the usefulness of ECTRs in poisoning.
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Affiliation(s)
- Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montreal, Montreal, Canada
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Müller D, Desel H. Common causes of poisoning: etiology, diagnosis and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:690-9; quiz 700. [PMID: 24194796 DOI: 10.3238/arztebl.2013.0690] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 07/31/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND In 2011, German hospitals treated approximately 205 000 patients suffering from acute poisoning. Change is seen over time both in the types of poisoning that occur and in the indications for specific treatment. METHODS This article is based on a selective review of the literature, with special attention to the health reports of the German federal government, the annual reports of the GIZ-Nord Poisons Center (the poison information center for the four northwestern states of Germany, i.e. Bremen, Hamburg, Lower Saxony and Schleswig-Holstein), and the recommendations of international medical associations. RESULTS From 1996 to 2011, the GIZ-Nord Poisons Center answered more than 450 000 inquiries, most of which involved exposures to medical drugs, chemicals, plants, foods, or cosmetics. Poisoning was clinically manifest in only a fraction of these cases. Ethanol intoxication is the commonest type of acute poisoning and suicide by medical drug overdose is the commonest type of suicide by poisoning. Death from acute poisoning is most commonly the result of either smoke inhalation or illegal drug use. Severe poisoning is only rarely due to the ingestion of chemicals (particularly detergents and cleaning products), cosmetics, or plant matter. Medical procedures that are intended to reduce the absorption of a poison or enhance its elimination are now only rarely indicated. Antidotes (e.g., atropine, 4-dimethylaminophenol, naloxone, toluidine blue) are available for only a few kinds of poisoning. Randomized clinical trials of treatment have been carried out for only a few substances. CONCLUSION Most exposures to poisons can be treated with general emergency care and, if necessary, with symptomatic intensive-care measures. Poison information centers help ensure that cases of poisoning are dealt with efficiently. The data they collect are a useful aid to toxicological assessment and can serve as a point of departure for research projects.
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Affiliation(s)
- Dieter Müller
- GIZ-Nord Poisons Center, University Medical Center Göttingen-Georg-August-Universität
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Jain M, Gupta S, Kaur S, Ponnusamy MP, Batra SK. Emerging trends for radioimmunotherapy in solid tumors. Cancer Biother Radiopharm 2013; 28:639-50. [PMID: 23844555 DOI: 10.1089/cbr.2013.1523] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Due to its ability to target both known and occult lesions, radioimmunotherapy (RIT) is an attractive therapeutic modality for solid tumors. Poor tumor uptake and undesirable pharmacokinetics, however, have precluded the administration of radioimmunoconjugates at therapeutically relevant doses thereby limiting the clinical utility of RIT. In solid tumors, efficacy of RIT is further compromised by heterogeneities in blood flow, tumor stroma, expression of target antigens and radioresistance. As a result significant efforts have been invested toward developing strategies to overcome these impediments. Further, there is an emerging interest in exploiting short-range, high energy α-particle emitting radionuclides for the eradication of minimal residual and micrometastatic disease. As a result several modalities for localized therapy and models of minimal disease have been developed for preclinical evaluation. This review provides a brief update on the recent efforts toward improving the efficacy of RIT for solid tumors, and development of RIT strategies for minimal disease associated with solid tumors. Further, some of promising approaches to improve tumor targeting, which showed promise in the past, but have now been ignored are also discussed.
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Affiliation(s)
- Maneesh Jain
- 1 Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center , Omaha, Nebraska
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High-throughput determination of barbiturates in human plasma using on-line column-switching ultra-fast liquid chromatography–tandem mass spectrometry. Forensic Toxicol 2012. [DOI: 10.1007/s11419-012-0155-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Roberts D, Chau A, Nair P, Day R. Enhanced elimination of phenobarbital using charcoal haemoperfusion in a patient with severe poisoning. Br J Anaesth 2011; 107:820-1. [DOI: 10.1093/bja/aer317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Comment on: “Emergency management of acute poisoning”. Afr J Emerg Med 2011. [DOI: 10.1016/j.afjem.2011.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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