Clinical pharmacy
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The chemistry, pharmacology, and pharmacokinetics of cocaine are described, and the medical complications of illicit cocaine use are reviewed. Cocaine is readily absorbed from mucous membranes, the gastrointestinal tract, and the vascular beds of the lungs. Thus there are a number of routes for illicit cocaine administration, with the most popular one being intranasal. ⋯ The treatment of cocaine-related toxicities is supportive and is based on the organ system affected. Drugs such as propranolol, labetalol, and nitrendipine have been advocated for treating the cardiovascular complications, and measures such as maintaining arterial blood pH, monitoring core body temperature, and diazepam therapy have been used to manage seizures. As the number of case reports of cocaine toxicity increases and the underlying mechanism is conclusively defined, management of the medical complications will improve.
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Randomized Controlled Trial Comparative Study Clinical Trial
Heparin sodium versus 0.9% sodium chloride injection for maintaining patency of indwelling intermittent infusion devices.
In a double-blind study, heparin sodium was compared with 0.9% sodium chloride injection for use in maintaining patency of indwelling devices for intermittent intravenous infusion. Adult patients who required intermittent intravenous devices were randomly assigned to receive 1 mL of a heparin sodium 100 units/mL flush solution or a 0.9% sodium chloride flush solution. Observations were recorded for each catheter, rather than for each patient. ⋯ The use of penicillins, cephalosporins, or clindamycin, alone or in combination, was significantly associated with the development of phlebitis for both treatment groups. No other factors were found to correlate with either the duration of catheter patency or incidence of phlebitis. The results of this study indicate that heparin offers no advantage over 0.9% sodium chloride injection in maintaining the patency of intermittent intravenous devices.
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The anatomy and physiology of the epidural space and the mechanism of action, sites of action, and pharmacokinetics of analgesics administered by continuous epidural infusion are reviewed, and the efficacy, adverse effects, and postoperative indications for use of analgesics administered by this route are discussed. Narcotics selectively block pain conduction by occupying specific opiate receptors in the spinal cord. Local anesthetics provide analgesia by axonal membrane blockade; they also can produce nonselective sympathetic and somatic (sensory and motor) blockade in addition to analgesia. ⋯ Adverse effects of epidurally administered local anesthetics include urinary retention, hypotension, numbness, motor weakness, tachyphylaxis, and, rarely, systemic toxicity. The cost of epidurally administered drugs is substantially higher than that for i.m. or i.v. narcotic analgesia, but this cost may be offset by other benefits such as a shorter hospital stay. Current studies suggest superior analgesia for the majority of surgical procedures with continuous epidural analgesia infusions compared with more traditional methods of providing analgesia.
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The clinical use of neuroleptics, benzodiazepines, narcotic analgesics, barbiturates, and neuromuscular blockers to manage delirium and agitation in the intensive-care setting is reviewed. Delirium is the most commonly encountered mental disturbance in critically ill patients and may be precipitated by factors such as physical illness, medications, pain, and emotional stress. If agitation cannot be controlled through nonpharmacologic means, pharmacologic intervention may be necessary. ⋯ Barbiturates are not recommended for routine use in the treatment of delirium and agitation. The use of neuromuscular blocking agents such as pancuronium bromide and metocurine iodide may be necessary when other therapies have failed. Haloperidol and the benzodiazepines, alone or in combination, are the drugs of choice for treatment of acute agitation and delirium in critically ill patients.
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The chemistry, pharmacology, pharmacokinetics, adverse effects, and dosage of clomipramine hydrochloride are described, and clinical studies of the use of clomipramine in treating obsessive-compulsive disorder (OCD), other psychiatric conditions, and chronic pain are reviewed. Clomipramine hydrochloride, a tricyclic antidepressant, is a potent inhibitor of serotonin reuptake and may affect dopaminergic neurotransmission, suppress rapid eye movement sleep, produce changes in electrocardiograms, and elevate plasma prolactin. The drug is well absorbed from the gastrointestinal tract and undergoes extensive first-pass metabolism. ⋯ The usual initial adult dosage is 25-50 mg/day, titrated gradually to 250 mg/day if necessary. Clomipramine hydrochloride is a welcome new agent for the treatment of obsessive-compulsive disorder. Although its adverse-effect profile is like that of other tricyclic antidepressants, sexual dysfunction and seizures may be more frequent with this agent and limit its use.