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Hayashi M, Strouse JJ, Veltri MA, Curtis BR, Takemoto CM. Immune thrombocytopenia due to Trimethoprim-Sulfamethoxazole; under-recognized adverse drug reaction in children? Pediatr Blood Cancer 2015; 62:922-3. [PMID: 25683320 PMCID: PMC4559584 DOI: 10.1002/pbc.25430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/22/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Masanori Hayashi
- Department of Pediatrics, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John J. Strouse
- Department of Pediatrics, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael A. Veltri
- Department of Pharmacy, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brian R. Curtis
- Platelet and Neutrophil Immunology Lab BloodCenter of Wisconsin, Milwaukee, WI
| | - Clifford M. Takemoto
- Department of Pediatrics, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD
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2
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Abstract
OBJECTIVES To inform pediatric cart-fill batch scheduling for reductions in pharmaceutical waste using a case study and simulation analysis. METHODS A pre and post intervention and simulation analysis was conducted during 3 months at a 205-bed children's center. An algorithm was developed to detect wasted medication based on time-stamped computerized provider order entry information. The algorithm was used to quantify pharmaceutical waste and associated costs for both preintervention (1 batch per day) and postintervention (3 batches per day) schedules. Further, simulation was used to systematically test 108 batch schedules outlining general characteristics that have an impact on the likelihood for waste. RESULTS Switching from a 1-batch-per-day to a 3-batch-per-day schedule resulted in a 31.3% decrease in pharmaceutical waste (28.7% to 19.7%) and annual cost savings of $183,380. Simulation results demonstrate how increasing batch frequency facilitates a more just-in-time process that reduces waste. The most substantial gains are realized by shifting from a schedule of 1 batch per day to at least 2 batches per day. The simulation exhibits how waste reduction is also achievable by avoiding batch preparation during daily time periods where medication administration or medication discontinuations are frequent. Last, the simulation was used to show how reducing batch preparation time per batch provides some, albeit minimal, opportunity to decrease waste. CONCLUSIONS The case study and simulation analysis demonstrate characteristics of batch scheduling that may support pediatric pharmacy managers in redesign toward minimizing pharmaceutical waste.
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Affiliation(s)
- Matthew F. Toerper
- Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Operations Integration, Johns Hopkins Health System, Baltimore, Maryland
| | - Michael A. Veltri
- Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Pediatric Division, Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Eric Hamrock
- Operations Integration, Johns Hopkins Health System, Baltimore, Maryland
| | - Nicole L. Mollenkopf
- Pediatric Division, Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kristen Holt
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Scott Levin
- Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Operations Integration, Johns Hopkins Health System, Baltimore, Maryland
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3
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Scharnweber C, Lau BD, Mollenkopf N, Thiemann DR, Veltri MA, Lehmann CU. Evaluation of medication dose alerts in pediatric inpatients. Int J Med Inform 2013; 82:676-83. [PMID: 23643148 DOI: 10.1016/j.ijmedinf.2013.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [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: 11/19/2012] [Revised: 04/02/2013] [Accepted: 04/03/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study evaluates the impact of 12,093 consecutive dose alerts generated by a computerized provider order entry system on pediatric medication ordering. PATIENTS AND METHODS All medication orders entered and all resulting medication dose alerts at the Johns Hopkins Children's Medical and Surgical Center in 2010, were retrospectively evaluated. Inclusion criteria were hospitalized patients less than 21 years old. There were no exclusion criteria. RESULTS During 2010, there were 7738 admissions for 5553 unique patients. A total of 182,308 medication orders for 1092 unique medications were submitted by providers. Six percent (11,155) of orders or order attempts generated alerts for 2046 patients and 524 medications. Two categories of alerts were analyzed: dose range alerts and informational alerts. 73.4% (8187) of all alerts were dose range alerts, with a compliance rate of 8.5% (694); 26.6% (2968) were informational alerts, with a compliance rate of 5.5% (163). CONCLUSIONS We found that underdosing alerts provide less value to providers than overdosing alerts. However, the low compliance with the alerts should trigger the evaluation of clinical practice behavior and the existing alert thresholds. Informational alerts noting the absence of established dosing guidelines had little effect on provider behavior and should be avoided when building a dose range alert system.
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Affiliation(s)
- Corinna Scharnweber
- Peter L. Reichertz Institute for Medical Informatics University of Braunschweig, Institute of Technology and Hannover Medical School, Germany.
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4
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Bembea MM, Rapan Parbuoni KA, Zimmer KP, Veltri MA, Shilkofski NA, McMillan-Nelson K, Lee CKK, Hunt EA. Characteristics of medication use during pediatric medical emergency team events and the role of a pharmacist-provided medication supply. J Pediatr Pharmacol Ther 2012; 17:236-45. [PMID: 23258966 DOI: 10.5863/1551-6776-17.3.236] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine the type and frequency of and indications for medications used during pediatric medical emergency team (PMET) events and to describe a PMET pharmacist training model, creation of a standardized "pharmacist PMET supply," and the pharmacist's role in implementation and ongoing improvement of a PMET. METHODS This is a retrospective observational cohort study of 210 PMET events in 172 patients in a tertiary care, academic pediatric hospital, from September 15, 2005, to September 15, 2007. We focused on the types and sources of medications used during PMET events. RESULTS The medications most commonly used were lorazepam (11%), neuromuscular blockers (10.5%), atropine (9.5%), epinephrine bolus (9%), and albuterol or levalbuterol (9%). However, 49 distinct medications were used in 53.8% of all PMET events. Of all medications requested during a PMET event, only 40% originated from an institutionally standardized emergency medication box, while an additional 35% were readily available at the patient's bedside as part of the "pharmacist PMET supply." CONCLUSIONS A wide variety of medications are required to care for children who suffer acute in-hospital deterioration. The pharmacist's medication supply and expertise ensured immediate availability of therapies for clinical entities ranging from seizures and anaphylaxis to rapid sequence intubation, regardless of the PMET event location.
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Affiliation(s)
- Melania M Bembea
- Departments of Anesthesiology and Critical Care, The Johns Hopkins University School of Medicine, Baltimore, Maryland ; Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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5
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Brown AT, Gillespie JV, Miquel-Verges F, Holmes K, Ravekes W, Spevak P, Brady K, Easley RB, Golden WC, McNamara L, Veltri MA, Lehmann CU, McMillan KN, Schwartz JM, Romer LH. Inhaled epoprostenol therapy for pulmonary hypertension: Improves oxygenation index more consistently in neonates than in older children. Pulm Circ 2012; 2:61-6. [PMID: 22558521 PMCID: PMC3342750 DOI: 10.4103/2045-8932.94835] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The purpose of this study was to determine the efficacy of inhaled epoprostenol for treatment of acute pulmonary hypertension (PH) in pediatric patients and to formulate a plan for a prospective, randomized study of pulmonary vasodilator therapy in this population. Inhaled epoprostenol is an effective treatment for pediatric PH. A retrospective chart review was conducted of all pediatric patients who received inhaled epoprostenol at a tertiary care hospital between October 2005 and August 2007. The study population was restricted to all patients under 18 years of age who received inhaled epoprostenol for greater than 1 hour and had available data for oxygenation index (OI) calculation. Arterial blood gas values and ventilator settings were collected immediately prior to epoprostenol initiation, and during epoprostenol therapy (as close to 12 hours after initiation as possible). Echocardiograms were reviewed during two time frames: Within 48 hours prior to therapy initiation and within 96 hours after initiation. Of the 20 patients in the study population, 13 were neonates, and the mean OI for these patients improved during epoprostenol administration (mean OI before and during therapy was 25.6±16.3 and 14.5±13.6, respectively, P=0.02). Mean OI for the seven patients greater than 30 days of age was not significantly different during treatment (mean OI before and during therapy was 29.6±15.0 and 25.6±17.8, P=0.56). Improvement in echocardiographic findings (evidence of decreased right-sided pressures or improved right ventricular function) was demonstrated in 20% of all patients. Inhaled epoprostenol is an effective therapy for the treatment of selected pediatric patients with acute PH. Neonates may benefit more consistently from this therapy than older infants and children. A randomized controlled trial is needed to discern the optimal role for inhaled prostanoids in the treatment of acute PH in childhood.
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Affiliation(s)
- Anna T Brown
- Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland, USA
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6
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Abstract
To prevent adverse drug events for pediatric patients, increase care provider efficiency, and reduce stress for care providers, a technology tool was developed that calculates medication dosage requirements during emergency situations. This article describes a simple low-cost technological solution for improving patient safety and care-provider assurance. Follow-up studies provide validation of the technology tool.
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Affiliation(s)
- Charles G Blackledge
- Center for Innovation in Quality Patient Care, Johns Hopkins Medical Institutions, USA.
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Abstract
OBJECTIVE To evaluate the effect of a Web-based calculator and decision-support system on infusion ordering errors and to estimate error frequency in pharmacy infusion preparation. DESIGN Data on ordering error frequency and typology were collected before and after implementation of an online infusion ordering system. Data on pharmacy preparation errors of infusions were collected. SETTING A children's hospital at an academic medical center. PATIENTS None. Data were abstracted from infusion orders. INTERVENTIONS Introduction of a voluntary-use Web-based calculator into infusion ordering workflow. Observation only. MAIN OUTCOME MEASURES Number and type of errors in handwritten and calculator-generated orders. Number and type of errors in pharmacy infusion preparation. RESULTS Before calculator deployment, 129 sequential handwritten infusion orders were collected over 5 weeks. After deployment, of 162 sequential infusion orders, 88% (142) were calculator-generated. Calculator-generated infusion orders contained 83% fewer (p < .001) orders containing one or more errors than handwritten orders. Calculator-generated orders contained no high-risk errors (incorrect decimal, dose, or unit of measure) when compared with handwritten orders and were associated with fewer pharmacy interventions. In 118 sequential pharmacy infusion preparations over 4 wks, there were no errors observed. CONCLUSION A Web-based calculator reduced significantly the total number of errors and eliminated all high-risk errors in the prescribing process for continuous pediatric infusions. With no observed errors in pharmacy preparation, this study provides data to support the use of computerized ordering as an independent safe and viable method for ordering continuous pediatric infusions.
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8
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Hamilton RG, Brown RH, Veltri MA, Feroli ER, Primeau MN, Schauble JF, Adkinson NF. Administering pharmaceuticals to latex-allergic patients from vials containing natural rubber latex closures. Am J Health Syst Pharm 2005; 62:1822-7. [PMID: 16120743 DOI: 10.2146/ajhp050021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Robert G Hamilton
- Johns Hopkins University Dermatology, Allergy and Clinical Immunology Reference Laboratory, Division of Allergy and Clinical Immunology, Department of Medicine, Baltimore, MD 21224, USA.
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9
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White JRM, Veltri MA, Fackler JC. Preventing adverse events in the pediatric intensive care unit: prospectively targeting factors that lead to intravenous potassium chloride order errors. Pediatr Crit Care Med 2005; 6:25-32. [PMID: 15636655 DOI: 10.1097/01.pcc.0000149832.76329.90] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To prospectively identify and reduce proximal causes of error contributing to inappropriate intravenous potassium chloride orders and reduce adverse events subsequent to these ordering errors. DESIGN Pre-post cohort study of the reduction in both proximal causes of error and number of postinfusion elevated serum potassium levels after intervention. SETTING Sixteen-bed, tertiary care, urban, academic pediatric intensive care unit. PATIENTS Children 0-18 yrs old receiving intravenous potassium chloride in the pediatric intensive care unit. INTERVENTIONS A multidisciplinary team determined proximal causes of error that were likely contributors to the occurrence of the outcome measure, elevated potassium levels after intravenous potassium chloride. A mandatory drug request form was designed for physicians ordering intravenous potassium chloride. The drug request form was designed to reduce proximal causes of error and, as a result, elevated potassium levels after intravenous potassium chloride. Demographic and laboratory data on children receiving intravenous potassium chloride in the pediatric intensive care unit and details of the drug order were analyzed. MEASUREMENTS AND MAIN RESULTS Data from 1,492 intravenous potassium chloride administration-events before implementation of the drug request form were collected. After the drug request form was mandated, 166 consecutively completed forms were collected and analyzed. The incidence of postinfusion elevations in serum potassium decreased from a rate of 7.7% (103 of 1,341) before the drug request form to 0% (0 of 150) after the drug request form (p < .001). Proximal causes of error were also reduced. The number of patients with a creatinine >/=2 mg/dL receiving intravenous potassium chloride decreased from 28.4% to 14.2% (p < .001). The number of intravenous potassium chloride infusions administered to patients where serum potassium value was >4.5 mmol/L decreased significantly (2.9% vs. 0.0%, p < .02). The incidence rates of both verbal orders and failure to write the order in a correct format were reduced to zero. CONCLUSIONS Simple, blame-free, system-wide interventions designed to reduce proximal causes of error can be an effective, proactive means of reducing the likelihood of medical morbidity.
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MESH Headings
- Adolescent
- Child
- Child, Preschool
- Drug Prescriptions/standards
- Drug Utilization Review
- Education, Medical, Continuing
- Hospitals, Teaching
- Humans
- Hyperkalemia/blood
- Hyperkalemia/chemically induced
- Incidence
- Infant
- Infant, Newborn
- Infusions, Intravenous/standards
- Intensive Care Units, Pediatric/standards
- Medical Staff, Hospital/standards
- Medication Errors/prevention & control
- Medication Errors/statistics & numerical data
- Medication Systems, Hospital/organization & administration
- Patient Care Team
- Potassium Chloride/administration & dosage
- Potassium Chloride/adverse effects
- Process Assessment, Health Care
- Prospective Studies
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Affiliation(s)
- Jeanette R M White
- Investigator Graduate Training Program in Clinical Investigation, the Johns Hopkins School of Medicine, Baltimore, MD, USA
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10
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Veltri MA, Neu AM, Fivush BA, Parekh RS, Furth SL. Drug dosing during intermittent hemodialysis and continuous renal replacement therapy : special considerations in pediatric patients. Paediatr Drugs 2004; 6:45-65. [PMID: 14969569 DOI: 10.2165/00148581-200406010-00004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Chronic renal failure is, fortunately, an unusual occurrence in children; however, many children with various underlying illnesses develop acute renal failure, and transiently require renal replacement therapy - peritoneal dialysis, intermittent hemodialysis (IHD), or continuous renal replacement therapy (CRRT). As children with acute and chronic renal failure often have multiple comorbid conditions requiring drug therapy, generalists, intensivists, nephrologists, and pharmacists need to be aware of the issues surrounding the management of drug therapy in pediatric patients undergoing renal replacement therapy. This article summarizes the pharmacokinetics and dosing of many drugs commonly prescribed for pediatric patients, and focuses on the management of drug therapy in pediatric patients undergoing IHD and CRRT in the intensive care unit setting. Peritoneal dialysis is not considered in this review. Finally, a summary table with recommended initial dosages for drugs commonly encountered in pediatric patients requiring IHD or CRRT is presented.
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Affiliation(s)
- Michael A Veltri
- Pediatric Division, Department of Pharmacy, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-6180, USA.
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11
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Moss WJ, Beers MC, Johnson E, Nichols DG, Perl TM, Dick JD, Veltri MA, Willoughby RE. Pilot study of antibiotic cycling in a pediatric intensive care unit. Crit Care Med 2002; 30:1877-82. [PMID: 12163809 DOI: 10.1097/00003246-200208000-00034] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [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: 11/26/2022]
Abstract
OBJECTIVE This pilot study was performed to determine the safety and size of effect of antibiotic cycling to reduce colonization and infection with antibiotic-resistant bacteria. DESIGN Open, observational study. SETTING The study was performed in a 16-bed pediatric medical-surgical intensive care unit. PATIENTS Critically ill children requiring antibiotic therapy. INTERVENTIONS Three antibiotic classes were systematically cycled for 3-month intervals over 18 months. Antibiotic regimens were used for all empirical therapy and continued if the bacterial isolate was susceptible. MEASUREMENTS The primary outcome was colonization with antibiotic-resistant bacteria, determined by surveillance cultures obtained twice monthly from all patients in the unit. Rates of antibiotic-resistant, nosocomial blood stream infections, and risks of colonization over calendar time in the intensive care unit were also evaluated. MAIN RESULTS The cycling of broad-spectrum, empirical antibiotics was safe and did not generate increased antibiotic resistance nor select for new organisms. Over the study period, the trend in prevalence of children colonized with antibiotic-resistant bacteria was from 29% to 24% (p =.41). The effect on prevalence of resistant blood stream infections was similar (p =.29). Changes in individual risks of colonization with resistant bacteria over calendar time were consistent with the ecologic effect in size and direction. CONCLUSIONS Results of this pilot intervention suggest that cycling antibiotics may be a safe and viable strategy to minimize the emergence of antibiotic resistance in intensive care units. A definitive study will require a randomized and controlled trial of only four pediatric intensive care units over an 18-month period.
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Affiliation(s)
- William J Moss
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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12
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Soloaga ED, Cáceres GA, Lyons GA, Veltri MA, Ubaldini JE, Chertcoff FJ. [Massive hemoptysis from an aortobronchial fistula]. Medicina (B Aires) 2002; 61:852-4. [PMID: 11808427] [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: 02/23/2023] Open
Abstract
This is a report of a 61 year old man who was admitted at the Intensive Care Unit because of massive hemoptysis and respiratory failure. Four years before he had had an aortic dissection type A, and at that time an aortic valve, ascending aorta and aortic arch replacement, had been carried out. A thorax CT scan showed an aneurysm of the ascending aorta. A bronchoscopy was normal. In the angiography, a collateral of the left mammary artery was identified as the cause of bleeding and was subsequently embolized. After the procedure, the patient had a new episode of massive hemoptysis, and surgery was recommended. During surgery, the diagnosis of aortobronchial fistula was confirmed but the patient died during the intervention.
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Affiliation(s)
- E D Soloaga
- Servicios de Terapia Intensiva, Hospital Británico de Buenos Aires.
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13
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Veltri MA, Conner KG. Physical compatibility of milrinone lactate injection with intravenous drugs commonly used in the pediatric intensive care unit. Am J Health Syst Pharm 2002; 59:452-4. [PMID: 11887412 DOI: 10.1093/ajhp/59.5.452] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Michael A Veltri
- Department of Pharmacy, Carnegie 180, The Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287-6180, USA.
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14
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Soloaga ED, Beltramo MN, Veltri MA, Ubaldini JE, Chertcoff FJ. [Acute respiratory failure due to lipoid pneumonia]. Medicina (B Aires) 2001; 60:602-4. [PMID: 11188900] [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: 02/19/2023] Open
Abstract
We report a 63 year old white man admitted to our hospital because of fever, productive cough and a severe respiratory failure. Bronchoalveolar lavage revealed a positive microscopy for acid-fast bacilli and a four drug scheme for tuberculosis was initiated. There was no improvement in the patient's condition and mechanical ventilation was needed. A thorax CT scan disclosed images that suggested lipoid pneumonia (lower lobes involvement, hypodensity and negative sign in the angiogram). At this point the patient's relatives indicated that he was a long term user of paraffin oil for chronic constipation. Treatment with high doses of steroids was initiated and after whole lung lavage, mechanical respiratory assistance could be interrupted. We comment the association of this entity with lung infections produced by atypical mycobacteria.
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Affiliation(s)
- E D Soloaga
- Servicios de Terapia Intensiva, Hospital Británico, Buenos Aires, Perdriel 74, 1280 Buenos Aires, Argentina.
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15
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Gonzalez Montaner LJ, Chertcoff FJ, Felgueras GM, Veltri MA, Ubaldini JE. Pulmonary air-fluid image. Chest 1983; 83:655-6. [PMID: 6403302 DOI: 10.1378/chest.83.4.655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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