Pharmacotherapy
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Adequate sleep, in terms of both quantity and quality, is an essential component of any overall health program. Sleep deprivation has serious deleterious effects on any subject, regardless of species. ⋯ The causes of sleep disturbance in the intensive care unit involve factors related to the underlying clinical condition, those due to the various drugs required to provide treatment and comfort, and those related to the environment and processes of care in the intensive care unit. Only through a comprehensive approach to intensive care can an environment that promotes sleep and revitalization be constructed and maintained.
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Since the 2002 publication of multidisciplinary clinical practice guidelines for intensive care unit (ICU) sedation and analgesia, additional information regarding adverse drug events has been reported. Our understanding of the risks associated with these sedative and analgesic agents promises to improve outcomes by helping clinicians identify and respond to therapeutic misadventures sooner. This review focuses on many issues, including the potentially fatal consequences associated with the propofol infusion syndrome, the evolving understanding of propylene glycol intoxication associated with parenteral lorazepam, new data involving high-dose and long-term dexmedetomidine therapy, haloperidol- and methadone-related prolongation of QTc intervals on the electrocardiogram, adverse events associated with atypical antipsychotics, and the potential for nonsteroidal antiinflammatory drugs to interfere with bone healing.
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Propofol (2,6-diisopropylphenol) is a potent intravenous hypnotic agent widely administered for induction and maintenance of anesthesia and for sedation in the intensive care unit. Propofol is insoluble in water and therefore is formulated in a lipid emulsion. In addition, a preservative (ethylenediaminetetraacetic acid [EDTA] or sodium metabisulfite) is added to retard bacterial growth. ⋯ Propofol also is a potent antioxidant. The added preservatives have biologic activity; EDTA has antiinflammatory properties, whereas metabisulfite may cause lipid peroxidation. The antiinflammatory and antioxidant properties of propofol may have beneficial effects in patients with sepsis and systemic inflammatory response syndrome.
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The burden of mental illness has been underestimated worldwide. Depression was the fourth leading cause of disease burden in the world in 1990 and is projected to be the second leading cause of disability by 2020. It is a leading cause of morbidity and mortality in the United States, costing billions of dollars annually in direct and indirect medical costs and losses in productivity. ⋯ In clinical trials, duloxetine was effective for the treatment of MDD and was well tolerated. Further study is needed to compare its efficacy with that of other antidepressants, to clarify effects on somatic symptoms, and to assess potential adverse cardiovascular and sexual side effects. Duloxetine is also approved for the management of diabetic peripheral neuropathic pain and is under investigation for the treatment of stress urinary incontinence in women.
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Clinical Trial
Validation of an insulin infusion nomogram for intensive glucose control in critically ill patients.
To evaluate the effectiveness, safety, and associated patient outcomes of a simplified, nurse-directed insulin nomogram designed to achieve intensive blood glucose level control (target range 90-144 mg/dl). ⋯ This study demonstrated that intensive blood glucose control is achievable using a nurse-directed nomogram. This improved control was achieved, regardless of diabetes status of the patient, without substantially compromising safety or increasing resource use.