The Annals of pharmacotherapy
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To describe 2 cases of clinically significant phenytoin removal during continuous venovenous hemofiltration (CVVH) and review the relevant literature regarding phenytoin removal by renal replacement modalities. ⋯ These cases demonstrate that a substantial amount-approximately 30%-of total daily phenytoin dose may be removed by CVVH, and patients may require higher than expected empiric doses. Phenytoin concentrations should be closely monitored in critically ill patients receiving CVVH.
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Case Reports
Inaccuracy of point-of-care international normalized ratio in rivaroxaban-treated patients.
To report 2 cases in which point-of-care international normalized ratios (POC-INRs) measured using a Hemochron Jr. Signature Elite device (International Technidyne Corporation) were inaccurate in rivaroxaban-treated patients. ⋯ Our 2 patients receiving rivaroxaban had POC-INRs elevated beyond what was expected; these measurements were discordant from INRs simultaneously measured via the laboratory. A prospective evaluation assessing the accuracy of other commonly used POC-INR devices in patients receiving rivaroxaban would determine whether our findings extend to other devices. Until that time, laboratory measurement of INR or POC-INR using an INRatio device is recommended when patients' therapy is transitioned from rivaroxaban to warfarin.
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Nearly all patients receive sedation and neuromuscular blockers (NMBs) during high-frequency oscillatory ventilation (HFOV). ⋯ High analgo-sedation doses were associated with APACHE II scores, worsening gas exchange, and NMB use. Two thirds of patients received NMBs; use was highest on day 1 and subsequently declined. The percentage of patients who received NMB during HFOV in our study was lower than that previously reported. Future research should evaluate patient outcomes with and without use of NMBs, as well as the potential to manage patients with less sedation.
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To report a case of tremors and agitation associated with the administration of low doses of intravenous hydromorphone in a patient with acute kidney injury in the setting of chronic kidney disease. ⋯ Neurotoxicity can occur in patients with kidney dysfunction while they receive low doses of intravenous hydromorphone over short periods. Diligent monitoring and reporting of such effects are necessary to better understand risk factors and a mechanism.
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Randomized Controlled Trial Comparative Study
Gabapentin versus chlordiazepoxide for outpatient alcohol detoxification treatment.
Benzodiazepines are used to treat alcohol withdrawal (AW) but cause cognitive impairment, sedation, and ataxia, and interact with alcohol. Nonbenzodiazepine anticonvulsants are promising and possibly safer alternatives for the treatment of AW. ⋯ In ambulatory veterans with symptoms of alcohol withdrawal, gabapentin treatment resulted in significantly greater reduction in sedation (ESS) and a trend to reduced alcohol craving (PACS) by the end of treatment compared to chlordiazepoxide treatment. Although limited by the small sample size, the suggestion of reduction in sleepiness and less craving warrants replication of the study with a larger sample.