Clinical pharmacy
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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 pharmacology and history of development of nondepolarizing neuromuscular blocking agents are presented, and the pharmacokinetics and pharmacodynamics of these agents, administration guidelines for mechanically ventilated patients, adverse effects, factors affecting paralysis, and methods for blockade reversal are reviewed. Nondepolarizing neuromuscular blocking agents (tubocurarine, metocurine, pancuronium, vecuronium, and atracurium) are frequently used to induce prolonged pharmacologic paralysis in patients in the intensive-care unit (ICU). These agents are poorly absorbed after oral administration and must be administered by injection, preferably by the i.v. route. ⋯ Generally, patients no longer requiring paralysis in the ICU will be allowed to spontaneously regain muscle function after drug therapy has been discontinued. If the effects of the nondepolarizing neuromuscular blocking agents must be reversed more rapidly, acetylcholinesterase-inhibiting agents such as physostigmine, neostigmine, pyridostigmine, and edrophonium can be used. Nondepolarizing neuromuscular blocking agents can be used to paralyze mechanically ventilated patients, facilitating optimal oxygenation and ventilation.
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Review Case Reports
Ampicillin-sulbactam therapy for multiple pyogenic hepatic abscesses.
A patient with multiple, pyogenic hepatic abscesses is described, and the pathophysiology, etiologies, clinical and laboratory manifestations, and management of the disease are reviewed. A 55-year-old man with a history of ethanol abuse and pancreatitis developed fever, chills, general malaise, and right upper quadrant abdominal pain two weeks before hospitalization. Baseline laboratory and hematology results included serum albumin concentration, 3.2 g/dL; serum alkaline phosphatase concentration, 239 mIU/mL; total serum bilirubin concentration, 1.3 mg/dL; white blood cell count, 18,400/cu mm; red blood cell count, 4.7 million/cu mm; hemoglobin, 12.5 g/dL; and hematocrit, 38.8%. ⋯ Abnormal laboratory values include leukocytosis, anemia, and hypoalbuminemia. The abscesses are frequently polymicrobial; Escherichia coli is the most commonly isolated species. CT is the best radiological technique for diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)
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Clinical studies of the injectable nonsteroidal anti-inflammatory agent (NSAIA) ketorolac tromethamine are reviewed, and the chemistry, pharmacology, pharmacokinetics, drug interactions, and adverse effects of ketorolac are described. Ketorolac exhibits anti-inflammatory, analgesic, and antipyretic activity. Although the exact mechanisms of action have not been determined, its effects appear to be associated principally with the inhibition of prostaglandin synthesis. ⋯ For short-term pain management, an initial i.m. ketorolac tromethamine loading dose of 30 or 60 mg is recommended. Ketorolac tromethamine appears to be as effective as morphine or meperidine for short-term management of moderate to severe postoperative pain. It lacks the respiratory depressant effects of opiate analgesics but shares the toxic potentials of other NSAIAs.
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The chemistry, pharmacology, pharmacokinetics, clinical efficacy, adverse effects, and dosage and administration of anistreplase in the treatment of acute myocardial infarction (AMI) are reviewed. Anistreplase is an acylated form of the streptokinase-plasminogen complex. Acylation makes the complex temporarily inactive but protects it from neutralization by plasmin inhibitors. ⋯ The recommended dose is 30 units i.v. given over two to five minutes. Anistreplase is similar in efficacy and safety to other thrombolytic agents in the treatment of AMI. The drug's ease of administration may be an important clinical consideration.