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Smit L, Slooter AJC, Devlin JW, Trogrlic Z, Hunfeld NGM, Osse RJ, Ponssen HH, Brouwers AJBW, Schoonderbeek JF, Simons KS, van den Boogaard M, Lens JA, Boer DP, Gommers DAMPJ, Rietdijk WJR, van der Jagt M. Efficacy of haloperidol to decrease the burden of delirium in adult critically ill patients: the EuRIDICE randomized clinical trial. Crit Care 2023; 27:413. [PMID: 37904241 PMCID: PMC10617114 DOI: 10.1186/s13054-023-04692-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 10/18/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND The role of haloperidol as treatment for ICU delirium and related symptoms remains controversial despite two recent large controlled trials evaluating its efficacy and safety. We sought to determine whether haloperidol when compared to placebo in critically ill adults with delirium reduces days with delirium and coma and improves delirium-related sequelae. METHODS This multi-center double-blind, placebo-controlled randomized trial at eight mixed medical-surgical Dutch ICUs included critically ill adults with delirium (Intensive Care Delirium Screening Checklist ≥ 4 or a positive Confusion Assessment Method for the ICU) admitted between February 2018 and January 2020. Patients were randomized to intravenous haloperidol 2.5 mg or placebo every 8 h, titrated up to 5 mg every 8 h if delirium persisted until ICU discharge or up to 14 days. The primary outcome was ICU delirium- and coma-free days (DCFDs) within 14 days after randomization. Predefined secondary outcomes included the protocolized use of sedatives for agitation and related behaviors, patient-initiated extubation and invasive device removal, adverse drug associated events, mechanical ventilation, ICU length of stay, 28-day mortality, and long-term outcomes up to 1-year after randomization. RESULTS The trial was terminated prematurely for primary endpoint futility on DSMB advice after enrolment of 132 (65 haloperidol; 67 placebo) patients [mean age 64 (15) years, APACHE IV score 73.1 (33.9), male 68%]. Haloperidol did not increase DCFDs (adjusted RR 0.98 [95% CI 0.73-1.31], p = 0.87). Patients treated with haloperidol (vs. placebo) were less likely to receive benzodiazepines (adjusted OR 0.41 [95% CI 0.18-0.89], p = 0.02). Effect measures of other secondary outcomes related to agitation (use of open label haloperidol [OR 0.43 (95% CI 0.12-1.56)] and other antipsychotics [OR 0.63 (95% CI 0.29-1.32)], self-extubation or invasive device removal [OR 0.70 (95% CI 0.22-2.18)]) appeared consistently more favorable with haloperidol, but the confidence interval also included harm. Adverse drug events were not different. Long-term secondary outcomes (e.g., ICU recall and quality of life) warrant further study. CONCLUSIONS Haloperidol does not reduce delirium in critically ill delirious adults. However, it may reduce rescue medication requirements and agitation-related events in delirious ICU patients warranting further evaluation. TRIAL REGISTRATION ClinicalTrials.gov (#NCT03628391), October 9, 2017.
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Affiliation(s)
- Lisa Smit
- Department of Intensive Care Adults, Erasmus MC-University Medical Centre, Room Ne-415, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - Arjen J C Slooter
- Departments of Psychiatry, Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, USA
| | - Zoran Trogrlic
- Department of Intensive Care Adults, Erasmus MC-University Medical Centre, Room Ne-415, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - Nicole G M Hunfeld
- Department of Intensive Care Adults, Erasmus MC-University Medical Centre, Room Ne-415, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Robert Jan Osse
- Department of Psychiatry, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Huibert H Ponssen
- Department of Intensive Care, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Arjen J B W Brouwers
- Department of Intensive Care Adults, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | | | - Koen S Simons
- Department of Intensive Care Medicine, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Judith A Lens
- Department of Intensive Care, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - Dirk P Boer
- Department of Intensive Care, Maasstad Hospital, Rotterdam, The Netherlands
| | - Diederik A M P J Gommers
- Department of Intensive Care Adults, Erasmus MC-University Medical Centre, Room Ne-415, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - Wim J R Rietdijk
- Department of Hospital Pharmacy, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC-University Medical Centre, Room Ne-415, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands.
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Theunisse C, Ponssen HH, de Graaf NTC, Scholten-Bakker M, Willemsen SP, Cheung D. The Effects of Low Pressure Domiciliary Non-Invasive Ventilation on Clinical Outcomes in Patients with Severe COPD Regardless Having Hypercapnia. Int J Chron Obstruct Pulmon Dis 2021; 16:817-824. [PMID: 33814905 PMCID: PMC8009340 DOI: 10.2147/copd.s289099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background The effectiveness of non-invasive home ventilation in patients with severe chronic obstructive pulmonary disease (COPD) is lacking. Non-invasive home ventilation might be more effective when high ventilator settings are used. However, high ventilator settings might reduce patient adherence. We have developed a multidisciplinary approach (ventilation practitioners, 24 hours support of respiratory nurses, physicians) to non-invasive ventilation aimed at optimizing patient adherence using low ventilator settings in severe COPD patients with high disease burden irrespectively having hypercapnia. Methods We included in a proof of concept, prospective interventional study, 48 GOLD stage III-IV COPD patients with a high disease burden (≥2 exacerbations in a year, and Medical Research Council dyspnea scores ≥3). Outcome measures included hospital admissions, capillary pCO2, Medical Research Council dyspnea scores (MRC), Clinical COPD Questionnaire scores (CCQ) and Hospital Anxiety and Depression Scale (HADS). Results After 1 year 32 patients could be evaluated. Hospital admissions decreased by 1.0 admission (mean difference ± SD: 1.0 ± 1.48; p = 0.001). In-hospital days decreased by 10.0 days (10.0 ± 15.48; p = 0.001). Capillary pCO2 decreased by 0.33 kPa (0.33 ± 0.81: p = 0.03). The MRC dyspnea score decreased by 0.66 (0.66 ± 1.35; p = 0.02). The CCQ score decreased by 0.59 (0.59 ± 1.39; p = 0.03). The HADS anxiety score decreased by 1.64 (1.64 ± 3.12; p = 0.01). The HADS depression score decreased by 1.64 (1.64 ± 3.91; p = 0.04). Conclusion A proof of concept multidisciplinary approach, using low pressure domiciliary non-invasive ventilation, aimed at optimizing patient adherence in severe COPD patients regardless having hypercapnia, reduced hospital admissions and improved symptoms and quality of life measures. This may imply that severe COPD patients with high disease burden, irrespective being hypercapnic, are candidates to be treated with low pressure domiciliary non-invasive ventilation.
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Affiliation(s)
- Christiaan Theunisse
- Department of Pulmonology, Albert Schweitzer Hospital, Dordrecht, the Netherlands.,Department of Intensive Care, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Huibert H Ponssen
- Department of Intensive Care, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Netty T C de Graaf
- Department of Pulmonology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | | | - Sten P Willemsen
- Department of Biostatics, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - David Cheung
- Department of Pulmonology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
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Smit L, Trogrlić Z, Devlin JW, Osse RJ, Ponssen HH, Slooter AJC, Hunfeld NGM, Rietdijk WJR, Gommers D, van der Jagt M. Efficacy of halopeRIdol to decrease the burden of Delirium In adult Critically ill patiEnts (EuRIDICE): study protocol for a prospective randomised multi-centre double-blind placebo-controlled clinical trial in the Netherlands. BMJ Open 2020; 10:e036735. [PMID: 32967873 PMCID: PMC7513600 DOI: 10.1136/bmjopen-2019-036735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Delirium in critically ill adults is associated with prolonged hospital stay, increased mortality and greater cognitive and functional decline. Current practice guideline recommendations advocate the use of non-pharmacological strategies to reduce delirium. The routine use of scheduled haloperidol to treat delirium is not recommended given a lack of evidence regarding its ability to resolve delirium nor improve relevant short-term and longer-term outcomes. This study aims to evaluate the efficacy and safety of haloperidol for the treatment of delirium in adult critically ill patients to reduce days spent with coma or delirium. METHODS AND ANALYSIS EuRIDICE is a prospective, multi-centre, randomised, double-blind, placebo-controlled trial. Study population consists of adult intensive care unit (ICU) patients without acute neurological injury who have delirium based on a positive Intensive Care Delirium Screening Checklist (ICDSC) or Confusion Assessment Method for the ICU (CAM-ICU) assessment. Intervention is intravenous haloperidol 2.5 mg (or matching placebo) every 8 hours, titrated daily based on ICDSC or CAM-ICU positivity to a maximum of 5 mg every 8 hours, until delirium resolution or ICU discharge. Main study endpoint is delirium and coma-free days (DCFD) up to 14 days after randomisation. Secondary endpoints include (1) 28-day and 1-year mortality, (2) cognitive and functional performance at 3 and 12 months, (3) patient and family delirium and ICU experience, (4) psychological sequelae during and after ICU stay, (4) safety concerns associated with haloperidol use and (5) cost-effectiveness. Differences in DCFDs between haloperidol and placebo group will be analysed using Poisson regression analysis. Study recruitment started in February 2018 and continues. ETHICS AND DISSEMINATION The study has been approved by the Medical Ethics Committee of the Erasmus University Medical Centre Rotterdam (MEC2017-511) and by the Institutional Review Boards of the participating sites. Its results will be disseminated via peer-reviewed publication and conference presentations. TRIAL REGISTRATION NCT03628391.
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Affiliation(s)
- Lisa Smit
- Department of Intensive Care Adults, Erasmus MC- University Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - Zoran Trogrlić
- Department of Intensive Care Adults, Erasmus MC- University Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - John W Devlin
- Department of Pharmacy and Health Systems Sciences, Northeastern University Bouve College of Health Sciences, Boston, Massachusetts, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Robert-Jan Osse
- Department of Psychiatry, Erasmus MC - University Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - Huibert H Ponssen
- Department of Intensive Care, Albert Schweitzer Hospital Location Dordwijk, Dordrecht, Zuid-Holland, Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Centre Utrecht Brain Centre, Utrecht, Utrecht, Netherlands
| | - Nicole G M Hunfeld
- Department of Pharmacy and Department of Intensive Care Adults, Erasmus MC - University Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - Wim J R Rietdijk
- Department of Intensive Care Adults, Erasmus MC- University Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - Diederik Gommers
- Department of Intensive Care Adults, Erasmus MC- University Medical Center, Rotterdam, Zuid-Holland, Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC- University Medical Center, Rotterdam, Zuid-Holland, Netherlands
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Trogrlić Z, Ista E, Ponssen HH, Schoonderbeek JF, Schreiner F, Verbrugge SJ, Dijkstra A, Bakker J, van der Jagt M. Attitudes, knowledge and practices concerning delirium: a survey among intensive care unit professionals. Nurs Crit Care 2016; 22:133-140. [PMID: 26996876 DOI: 10.1111/nicc.12239] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Delirium is a common form of vital organ dysfunction in intensive care unit (ICU) patients and is associated with poor outcomes. Adherence to guideline recommendations pertaining to delirium is still suboptimal. AIMS We performed a survey aimed at identifying barriers for implementation that should be addressed in a tailored implementation intervention targeted at improved ICU delirium guideline adherence. DESIGN The survey was conducted among ICU professionals. METHODS An online survey was conducted among 360 ICU health care professionals (nurses, physicians and delirium consultants) from six ICUs in the southwest of the Netherlands as part of a multicentre prospective implementation project [response rate: 64% of 565 invited; 283 (79%) were nurses]. RESULTS Although the majority (83%) of respondents considered delirium a common and major problem in the ICU, we identified several barriers for implementation of a delirium guideline. The most important barriers were knowledge deficit, low delirium screening rate, lack of trust in the reliability of delirium screening tools, belief that delirium is not preventable, low familiarity with delirium guidelines, low satisfaction with physician-described delirium management, poor collaboration between nurses and physicians, reluctance to change delirium care practices, lack of time, disbelief that patients would receive optimal care when adhering to the guideline and the perception that the delirium guideline is cumbersome or inconvenient in daily practice. CONCLUSION Although ICU professionals consider delirium a serious problem, several important barriers to adhere to guidelines on delirium management are still present today. RELEVANCE TO CLINICAL PRACTICE Identification of implementation barriers for adherence to guidelines pertaining to delirium is feasible with a survey. Results of this study may help to design-targeted implementation strategies for ICU delirium management.
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Affiliation(s)
- Zoran Trogrlić
- Department of Intensive Care, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - Erwin Ista
- Department of Pediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, the Netherlands
| | - Huibert H Ponssen
- Department of Intensive Care, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | | | - Frodo Schreiner
- Department of Intensive Care, IJsselland Hospital, Rotterdam, the Netherlands
| | - Serge J Verbrugge
- Department of Intensive Care, Sint Franciscus Gasthuis, Rotterdam, the Netherlands
| | - Annemieke Dijkstra
- Department of Intensive Care, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Jan Bakker
- Department of Intensive Care, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
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van de Ven ART, van Vliet ACM, Maraha B, Ponssen HH. Fibrinolytic therapy in Capnocytophaga canimorsus sepsis after dog bite. Intensive Care Med 2004; 30:1980. [PMID: 15232682 DOI: 10.1007/s00134-004-2387-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2004] [Indexed: 10/26/2022]
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Kiewiet RM, Ponssen HH, Janssens ENW, Fels PW. Ventricular fibrillation in hypercalcaemic crisis due to primary hyperparathyroidism. Neth J Med 2004; 62:94-6. [PMID: 15209475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
We report the case of a 64-year-old man who presented with severe hypercalcaemia secondary to primary hyperparathyroidism. Soon after admission he developed ventricular fibrillation with no other cause than this severe hypercalcaemia. Although the occurrence of cardiac arrhythmias in hypercalcaemia is widely known, ventricular fibrillation has never been described before.
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Affiliation(s)
- R M Kiewiet
- Department of Internal Medicine, Albert Schweitzer Hospital, PO Box 444 3300o AH Dordrecht, the Netherlands.
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7
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van Marum RJ, Jansen S, Ponssen HH. [Antipsychotic medication as a cause of deep hypothermia]. Ned Tijdschr Geneeskd 2003; 147:1201-4. [PMID: 12848053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Two patients were presented at our hospital with hypothermia following dose adjustment of antipsychotic medication. The first patient, a mentally retarded 45-year-old man developed a temperature of 31.7 degrees C several days after starting of levomepromazine. The second patient, an 41-year-old schizophrenic man, whose risperidone dose had been increased following a psychotic crisis, developed deep hypothermia (temperature 29.7 degrees C) and severe respiratory insufficiency requiring pressure support ventilation. Both patients were admitted to the ICU and recovered completely. Antipsychotics influence hypothalamic thermoregulation and may induce hypothermia by stimulating dopamine (mainly D2) receptors and blocking 5-HT2 receptors. Furthermore, antipsychotics may reduce the shivering capability and can cause peripheral vasodilatation and reduced shunting by blocking skin alpha 1 receptors. Hypothermia can be a lethal condition. When a patient's clinical condition deteriorates following the start of antipsychotic medication, the presence of hypothermia should be excluded.
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te Velde LF, Ponssen HH, Koopman-van Gemert AWMM. [Reduced risk of complications associated with severe acute (necrotizing) pancreatitis by administration of antibiotics; results from a literature review]. Ned Tijdschr Geneeskd 2002; 146:534-5. [PMID: 11925809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Miesen WM, Ponssen HH, Jansen S, Posthuma RM, van Vliet AC. Aerosolized prostacyclin in acute respiratory distress syndrome caused by Chlamydiaceae spp. pneumonia. Neth J Med 2001; 59:57-61. [PMID: 11476913 DOI: 10.1016/s0300-2977(01)00120-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Management of respiratory failure in acute respiratory distress syndrome (ARDS) typically requires ventilatory assistance. If traditional approaches to mechanical ventilation and adjunctive measures fail to succeed in achieving adequate oxygenation, alternative measures should be considered. We describe an ARDS patient with respiratory failure caused by a severe Chlamydiaceae species community-acquired pneumonia (CAP). Aerosolized prostacyclin (PGI(2)) treatment was successfully instituted for refractory hypoxemia.
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Affiliation(s)
- W M Miesen
- Department of Internal Medicine, Division of Intensive Care, Albert Schweitzer Hospital, Location Amstelwijck, P.O. Box 444, 3300 AK Dordrecht, The Netherlands
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van Oers JA, Ponssen HH, Hesp WL. Pneumopericardium, pneumomediastinum, pericarditis and mediastinal abscess secondary to diverticulitis of the sigmoid. Intensive Care Med 2000; 26:1867-8. [PMID: 11271098 DOI: 10.1007/s001340000711] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Carels RA, Ponssen HH, van Vliet AC. [Meperidine (pethidine) outdated as analgesic in acute pancreatitis]. Ned Tijdschr Geneeskd 2000; 144:1855. [PMID: 11020843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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12
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van Bommel EF, Kalmeijer MD, Ponssen HH. Treatment of life-threatening lithium toxicity with high-volume continuous venovenous hemofiltration. Am J Nephrol 2000; 20:408-11. [PMID: 11093000 DOI: 10.1159/000013627] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
There is still debate as to the preferred extracorporeal treatment modality for severe lithium intoxication. Because lithium is readily diffusable, intermittent hemodialysis is usually performed. However, this bares the risk of a post-dialysis rebound concentration and, in the case of severe lithium poisoning collapse, aggravation of hemodynamic instability. Because of the relatively slow but continuous solute removal, continuous renal replacement therapy (CRRT) may be advantageous. We report the first case in the literature of severe lithium intoxication treated effectively with high-volume continuous venovenous hemofiltration (HV-CVVH). Results compared favorably to other forms of CRRT in terms of lithium clearance. Ease of implementation, the excellent tolerability and the superior lithium clearance without rebound phenomenon may make HV-CVVH the preferred treatment modality for severe lithium poisoning.
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Affiliation(s)
- E F van Bommel
- Department of Medicine, Albert Schweitzer Hospital, Location Amstelwijck, Dordrecht, The Netherlands
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Abstract
OBJECTIVE This study was undertaken to assess the effects of combined treatment with insulin and metformin in patients with type 2 diabetes mellitus in whom dietary measures, weight control, and oral antihyperglycemic therapy had failed. BACKGROUND Insulin resistance in peripheral tissues, increased hepatic gluconeogenesis, and impaired insulin secretion are the underlying factors in the development of type 2 diabetes. Metformin is a biguanide antihyperglycemic agent that increases peripheral insulin sensitivity, reduces hepatic gluconeogenesis, and decreases intestinal glucose absorption. METHODS Thirty-one patients (24 women, 7 men; mean age, 61.8 years; mean body mass index [BMI], 28.0 kg/m2) were enrolled in this randomized, double-blind, 2-way, crossover, placebo-controlled study. Patients with type 2 diabetes who were treated previously with insulin or oral hypoglycemic agents and who had a glycosylated hemoglobin (HbA1c) level >9% or a fasting blood glucose level >8 mmol/L were included. Patients who were being treated with oral agents were switched to insulin therapy and required to maintain stable blood glucose control for 2 months prior to randomization. Patients received insulin plus either metformin 1,700 mg/d or placebo for 5 months, followed by a 2-month washout period, and were then crossed over to the other treatment arm for 5 months of additional treatment (total treatment period: 12 months). RESULTS Thirty patients completed the study; 1 patient withdrew early because of hypoglycemia. Compared with placebo, metformin produced significant reductions from overall baseline in mean daily insulin dose requirement (-8.69 units (17.2%], P < 0.001), HbA1c level (-0.74 [9.9%], P = 0.005), serum fructosamine level (-44.40 micromol/L, P = 0.026), 24-hour blood glucose profile (P = 0.008), and total cholesterol level (-0.42 mmol/L, P = 0.005). No treatment effects were observed on body weight, blood pressure, serum high-density lipoprotein cholesterol levels, or serum triglyceride levels. There was no correlation between BMI and reduction in HbA1C. No major side effects were reported. CONCLUSIONS Combination therapy with metformin and insulin improves glycemic control and reduces insulin requirements. with no major side effects, in patients with type 2 diabetes and may improve the risk profile in this patient population.
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Affiliation(s)
- H H Ponssen
- Sint Franciscus Gasthuis, Rotterdam, The Netherlands
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Abstract
Cyanosis is usually caused by decreased arterial oxygen saturation due to pulmonary or cardiac diseases. Methemoglobinemia is a rare cause, sometimes with lethal outcome. Two patients are described, both with an unremarkable cardiopulmonary history, presented with severe cyanosis due to aniline-induced methemoglobinemia that developed at work. The symptoms and the treatment of methemoglobinemia are discussed.
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Affiliation(s)
- H Demirel
- Department of Internal Medicine, Drechtsteden Ziekenhuis, AK Dordrecht, The Netherlands
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Vergunst-van Keulen JG, Roodenburg-de Kluyver N, Ponssen HH, van Vliet AC. [Iatrogenous pressure pneumothorax due to incorrect placement of the feeding tube]. Ned Tijdschr Geneeskd 1998; 142:1348-9. [PMID: 9752046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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van der Aa RP, Berk L, Mahabier C, Ponssen HH, van Vliet AC. [An amebic abscess in the liver; early suspicion, late detection]. Ned Tijdschr Geneeskd 1997; 141:2418. [PMID: 9678989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Abstract
Despite impressive advances in the field of general intensive care and in the techniques available for the treatment of acute renal failure (ARF), particularly the development of continuous renal replacement therapies (CRRT), it is suggested that outcome of ARF patients has remained similar to that observed 2 or more decades ago. This article focuses on the impact of several factors, including the dialysis regimen, on outcome in ARF patients in a recent time period compared with an earlier period to assess whether a change has occurred in the patient population, dialysis regimen, or renal and patient outcome. Critical differences between intermittent hemodialysis (IHD) and CRRT and the authors' preference for continuous venovenous hemofiltration (CWH) are explained. However, using the APACHE II score and more specifically use of the ratio between this score at 2 different time points (ICU admission v time of start of dialysis), the need for an easy-to-use and reliable severity-of-illness score to allow adequate comparison of patient groups or treatment strategies is emphasized. Using data from a recent survey, attention is also given to the implementation of acute dialytic support, particularly CRRT, in the Netherlands.
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Affiliation(s)
- E F van Bommel
- Department of Internal Medicine, Drechtsteden Hospital, Dordrecht, The Netherlands
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Ponssen HH, de Herder WW, Bonjer HJ, Wauters CC, Krenning EP, Lamberts SW. An unusual case of multiple endocrine neoplasia type 1 and the role of 111In-pentetreotide scintigraphy. Neth J Med 1996; 49:112-5. [PMID: 8854674 DOI: 10.1016/0300-2977(96)00013-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A 50-year-old woman is described with a very unusual combination of MEN-1 syndrome with a negative family history. At first she had been treated because of a clinically non-functioning pituitary adenoma in the maxillary sinus. Six years later a carcinoid tumour was discovered by means of 111In-pentreotide scintigraphy.
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Affiliation(s)
- H H Ponssen
- Department of Internal Medicine 3, University Hospital Rotterdam, Netherlands
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