Pharmacotherapy
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To evaluate diagnostic tests for heparin-induced thrombocytopenia (HIT), a serious drug reaction that can occur in patients receiving heparin, and to evaluate treatment with direct thrombin inhibitors-the only initial drug therapy that decreases the risk of thromboembolism associated with immune-mediated HIT. ⋯ Due to supratherapeutic activated partial thromboplastin times, our patients often required doses of argatroban and lepirudin lower than those usually recommended. Thus, direct thrombin inhibitors should be started at low initial doses and titrated to target activated partial thromboplastin times to achieve appropriate efficacy and to avoid increasing the risk of bleeding. Platelet-aggregation tests were least useful for evaluating HIT. Appropriate diagnostic strategies should be used to avoid unnecessary drug use.
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Randomized Controlled Trial Comparative Study
Comparison of methods for intravenous infusion of fat emulsion during extracorporeal membrane oxygenation.
To characterize the effects of infusing fat emulsion during neonatal extracorporeal membrane oxygenation (ECMO) by comparing results from patients receiving fat emulsion through the ECMO circuit with those receiving fat emulsion through separate intravenous access. A second goal was to identify the optimal route for administration. ⋯ Although both methods were associated with layering out, agglutination, and clot formation, these effects occurred more frequently with administration into the ECMO circuit, particularly in areas of stasis. This may result in disruption of normal ECMO blood flow and impaired delivery of calories. Fat emulsion should therefore be administered through separate intravenous access during ECMO whenever possible.
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Review
Effects of perioperative antiinflammatory and immunomodulating therapy on surgical wound healing.
Patients with various rheumatologic and inflammatory disease states commonly require drugs known to decrease the inflammatory or autoimmune response for adequate control of their condition. Such drugs include nonsteroidal antiinflammatory drugs (NSAIDs), cyclooxygenase (COX)-2 inhibitors, corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and biologic response modifiers. These drugs affect inflammation and local immune responses, which are necessary for proper wound healing in the perioperative setting, thereby potentially resulting in undesirable postoperative complications. ⋯ In some cases, discontinuation of therapy may be required up to 4 weeks before surgery because of the long half-lives of the drugs. In doing so, patients may experience an exacerbation or worsening of disease. Clinicians must carefully evaluate individual patient risk factors, disease severity, and the pharmacokinetics of available therapies when weighing the risks and benefits of discontinuing therapy in the perioperative setting.
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Review
Antimicrobial resistance in the hospital setting: impact, trends, and infection control measures.
The growing threat posed by antibiotic-resistant pathogens is a major challenge for infectious disease practitioners and public health officials. In recent years, the prevalence of resistance among key bacterial pathogens, including Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Streptococcus pneumoniae, and Enterococcus sp, has increased at an alarming rate. ⋯ To control the spread of resistance and subsequent impact, a multifaceted approach is warranted. Awareness and surveillance of antimicrobial resistance, prudent use of antibiotics, and compliance with infection control techniques may help contain the emergence and spread of resistant organisms.
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To characterize the frequency, severity, risk factors, and clinician response to propofol-associated hypertriglyceridemia and hypertriglyceridemia-associated pancreatitis. ⋯ Hypertriglyceridemia and hypertriglyceridemia-associated pancreatitis are often seen in intensive care patients receiving propofol. Serum triglyceride concentrations should be routinely monitored in these patients. In addition, alternative sedation strategies should be considered when hypertriglyceridemia is detected.