American journal of therapeutics
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To evaluate whether initial orders of pain medications by physicians for trauma patients were in accordance with published guidelines. ⋯ The majority of patients in this investigation were initially prescribed appropriate doses and intervals for pain management.
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To review the mechanism and cause of hemostatic defects following cardiopulmonary bypass (CPB) and determine the safety and efficacy of antifibrinolytic agents for use in cardiac surgery and patients likely to benefit. DATA SOURCES: A MEDLINE search (1966 to present) of the English-language literature pertaining to aminocaproic acid (ACA), tranexamic acid (TA), and aprotinin was performed. Additional literature was obtained from reference citations of pertinent articles identified through the search. STUDY SELECTION AND DATA EXTRACTION: While all articles of relevance were considered for inclusion, this review evaluates only clinical trials with emphasis on prospective, randomized, controlled studies. DATA SYNTHESIS: In reported trials, ACA and TA each reduce mediastinal blood losses by about one-third, while transfusion needs remain unchanged. ACA and TA dosing inconsistencies, omission of transfusion criteria, and unidentified surgical risk factors prevent optimal findings. Thromboembolic complications could not be ascribed to either ACA or TA in more than 950 patients studied. Aprotinin decreased mean mediastinal blood losses by 42%, 67% and 48% in primary coronary artery bypass grafting (CABG), reoperative CABG, and in CABG patients receiving aspirin, respectively. Transfusion needs were reduced 42% in primary CABG patients and 55% to 88% in high-risk patients. Patients at high risk of bleeding (i.e., reoperative CABG and patients on aspirin) demonstrated greater transfusion needs and blood loss than primary CABG patients. As blood conservation measures may eliminate the need for transfusions among primary CABG patients, patients at higher risk may benefit most from the addition of antifibrinolytic prophylaxis. ⋯ The efficacy of all antifibrinolytic agents in cardiac surgery has been established, but comparative data is inconclusive to suggest an agent of choice. Thromboembolic complications have been rare and difficult to ascribe to antifibrinolytic agents. Future trials comparing efficacy of agents in high risk patients and rigorously evaluating thromboembolic events will allow unconditional recommendations.
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The purpose of this project was to evaluate the analgesic efficacy of misoprostol when combined with ibuprofen or diclofenac Na. Animal experiments using the inflamed rat paw formalin model suggested that misoprostol potentiates the analgesic effect of some NSAIDs (nonsteroidal anti-inflammatory drugs) including diclofenac Na but not propionic acid derivatives or opiates. The dental pain model was used to evaluate the clinical relevance of this interaction. ⋯ Both studies demonstrated that misoprostol 200 &mgr;g, a prostaglandin analog, does have an analgesic effect. When combined with ibuprofen, there was no potentiation of analgesia. In contrast, the combination of misoprostol + diclofenac Na demonstrated an enhanced peak effect, total effect for pain intensity difference and pain relief (sum pain intensity difference [SPID] and total pain relief [TOTPAR]), and
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Painful episodes are the most frequent complaints of patients with sickle cell disease. The Emergency Department (ED) has provided management for acute events using the usual triage format for emergencies. A prospective study evaluated the role of the ED in the care of adults with sickle cell disease (SCD). ⋯ Absolute indications for admission include sepsis, fever >102 degreeF, white cell counts >20 000, worsening anemia, hypoxemia, acute chest syndrome and new CNS events. Patient database in the ED must be revised annually to avoid extensive workup in the ED and a complete history/physical examination, and a CBC could be sufficient for triage in an uncomplicated pain crisis. An acceptable protocol for care should be available at all EDs and a registry and information system for SCD will discourage overutilization of investigational tests and visits to multiple EDs.