DICP

Broyles, Joyce E.; Brown, Rex O.; Vehe, Kathryn L.; Nolly, Robert J.; Luther, R. Wayne

doi: 10.1177/106002809102500201pmid: 1905438

Many intensive care unit (ICU) patients require parenteral nutrition (PN) and fluid restriction, making delivery of adequate nutrition difficult. We studied the effects of pharmacist interventions on fluid balance in fluid-restricted ICU patients requiring PN. Twenty patients were randomized to the treatment group (dextrose 70% injection [D70W] plus 15% amino acids for PN, 25-mL piggybacks, selected drugs added to the PN solution) or the control group (D70W plus 10% amino acids, 50- or 100-mL piggybacks). Each group contained 10 patients and they were not significantly different for age, gender, weight, hospital days, and serum albumin concentration. The duration (9.3 ± 1.2 vs. 9.7 ± 2.4 d) and doses of PN (29 ± 6.8 vs. 28.7 ± 6.9 kcal/kg/d; 1.1 ± 0.3 vs. 1.1 ± 0.4 g/kg/d protein) were similar between treatment and control groups. Mean fluid intake (3112 ± 1146 vs. 3498 ± 1111 mL/d), fluid balance (146 ± 1581 vs. 708 ± 1402 mL/d), and cumulative fluid balance (1358 vs. 6867 mL) were all significantly lower in the treatment group. Mean fluid output was similar between the two groups. Pharmacist interventions can significantly decrease intake and result in a better fluid balance in fluid-restricted ICU patients who require PN.

Raymond, Glynn G.; Davis, Robin L.

doi: 10.1177/106002809102500202pmid: 2058182

The physical compatibility and chemical stability of amphotericin B for injection USP (AB) admixed with magnesium sulfate injection USP (MS) in 5% dextrose injection USP (D5W) was evaluated. AB (final concentration of either 40 or 80 μg/mL of solution) and MS (final concentration of 0, 2, or 4 mg/mL of solution) were mixed in glass volumetric flasks containing D5W. AB concentration, as quantitated by high-performance liquid chromatography, and visible admixture clarity were monitored at zero, three, and six hours after combining with MS. At the three-hour observation, visible admixture clarity appeared to decrease in all multiple drug combinations and a clear supernatant began to develop as particulates settled to the bottom of the container. MS (final concentration of 4 or 8 mg/mL of solution) and AB (final concentration of 80 μg/mL of solution) were prepared in two separate intravenous polyvinyl chloride bags of D5W. The solutions were manually set to infuse via gravity for six hours and mix at the y-site of an intravenous administration set. Samples of the mixture were collected from the terminal end of a primary intravenous administration set at zero, two, four, and six hours after beginning the infusions. Each sample appeared visibly clear and maintained an AB concentration of at least 100 percent of the initial admixture concentration. MS and AB mixed in the same container appeared to be physically incompatible. The same admixture appeared to be physically compatible and chemically stable, in terms of AB, when infused as separate solutions mixed at a y-site of an intravenous administration set.

Thomson, Alison H.; Grant, Alexander C.; Rodger, R. Stuart C.; Hughes, Roger L.

doi: 10.1177/106002809102500203pmid: 2058183

The dispositions and dose requirements for vancomycin and gentamicin were investigated in a 58-year-old man who was receiving long-term continuous venovenous hemofiltration. Estimates of clearance were obtained using a Bayesian parameter estimation program and stayed remarkably consistent throughout the therapy. Single daily doses of both vancomycin and gentamicin generally maintained the profiles for both drugs around the target ranges of peak 5–10 mg/L (gentamicin) and 25–40 mg/L (vancomycin) and trough <2 mg/L (gentamicin) and <10 mg/L (vancomycin).

Chan, C.Y. Jennifer; Wallander, Kay A.

doi: 10.1177/106002809102500204pmid: 2058184

Diphenhydramine hydrochloride is an antihistamine with anticholinergic properties that is frequently used both orally and topically for the temporary relief of pruritus. Significant systemic absorption may occur following topical administration of diphenhydramine in patients with varicella-zoster lesions. We describe three children with varicella-zoster infection (VZI) who developed bizarre behavior as well as visual and auditory hallucinations following topical applications of large amounts of diphenhydramine to the majority of skin surfaces. In two cases, oral diphenhydramine was also administered. Serum diphenhydramine concentrations approximated or exceeded those previously reported. In each case, a complete resolution of mental status abnormalities occurred within 24 hours after discontinuation of all diphenhydramine-containing products. Pharmacists and other health professionals should be aware of the potential toxicity of topical diphenhydramine in patients with VZI.

Morton, Mark R.; Robbins, Marshall E.

doi: 10.1177/106002809102500205pmid: 1905439

Misoprostol has been associated with adverse reactions, including gastrointestinal symptoms, gynecologic problems, and headache. Changes in mental status, however, have not been reported. We present a case in which an 89-year-old woman in a long-term care facility became confused after the initiation of misoprostol therapy. The patient's change in mental status was first reported nine days after the initiation of therapy. Her delirium significantly improved after misoprostol was discontinued and her mental status returned to normal within a week. Because no other factors related to this patient changed significantly, the delirium experienced by this patient possibly resulted from misoprostol therapy.

Hull, Robert Lee; Brandon, Donald

doi: 10.1177/106002809102500206pmid: 2058185

Thrombocytopenia is defined as a decrease in the platelet count to <100 × 109/L and it is the most commonly reported drug-induced blood dyscrasia. Heparin is the most commonly reported cause of drug-induced thrombocytopenia with a reported incidence between one and ten percent. Thrombocytopenia induced by cephalosporins has been reported but is relatively rare. This report does not completely document that two third-generation cephalosporins caused platelet counts to fall <100 × 109/L in the patient described but there was no other explanation available. Platelet counts began to fall with the institution of third-generation cephalosporins and began to rise when these agents were stopped. In order to document that thrombocytopenia was induced by the third-generation cephalosporins a rechallenge would have been necessary; this was not considered to be safe in this patient. A review of the literature is presented describing similar cases of cephalosporin-induced thrombocytopenia.

doi: 10.1177/106002809102500207pmid: N/A

Fitzgerald, Jill Mancini; Marsh, T. Donald

doi: 10.1177/106002809102500208pmid: 1676200

Sulfasalazine has been used for many years in the management of ulcerative colitis. As many as 20 percent of patients treated with it experience intolerable adverse effects usually attributed to its sulfapyridine component. The other active component is 5-aminosalicylic acid (5-ASA); the only 5-ASA enema preparation currently available in the U.S. is mesalamine (Rowasa, Reid-Rowell) containing 5-ASA 4 g in 60 mL. In clinical trials, mesalamine has proved efficacious in treating refractory cases of distal ulcerative colitis, proctitis, and proctosigmoiditis. Because of its high cost compared with more conventional treatment modalities, it should be reserved for cases that are either refractory or intolerant to conventional treatment.

Hansen, Lea Ann; Hughes, Thomas E.

doi: 10.1177/106002809102500209pmid: 1905441

Altretamine is a National Cancer Institute-designated group C antineoplastic agent used in the treatment of advanced ovarian cancer. Altretamine is a highly lipid-soluble drug available only for oral administration as a capsule. The drug is activated through metabolic oxidation to intermediate methylol derivatives and formaldehyde. It is unclear which metabolite is the major species responsible for cytotoxicity or the primary mechanism of cytotoxicity. As a single agent in the treatment of ovarian cancer, altretamine demonstrates a response rate similar to other active agents in this disease (21–39 percent). The major utility of altretamine is in combination with other agents such as cyclophosphamide, doxorubicin, fluorouracil, melphalan, and cisplatin. However, few randomized trials have evaluated the contribution of altretamine in these multiagent combinations. Dose-limiting toxicities include gastrointestinal (nausea, vomiting, anorexia), hematologic, and neurotoxic (peripheral neurotoxicity). The therapeutic role of altretamine is limited because of a toxicity profile similar to that of cisplatin, one of the more active agents in ovarian cancer. Its use should be reserved for patients who are not candidates for more standard platinum-based regimens.

Zhanel, George G.; Hoban, Daryl J.; Harding, Godfrey K.M.

doi: 10.1177/106002809102500210pmid: 2058187

The term postantibiotic effect (PAE) refers to a period of time after complete removal of an antibiotic during which there is no growth of the target organism. The PAE appears to be a feature of most antimicrobial agents and has been documented with a variety of common bacterial pathogens. Several factors influence the presence or duration of the PAE including the type of organism, type of antimicrobial, concentration of antimicrobial, duration of antimicrobial exposure, and antimicrobial combinations. In vitro, beta-lactam antimicrobials demonstrate a PAE against gram-positive cocci but fail to produce a PAE with gram-negative bacilli. Antimicrobials that inhibit RNA or protein synthesis produce an in vitro PAE against gram positive cocci and also produce a PAE against gram-negative bacilli. In vitro methods used to determine the PAE include colony counts, optical density, and measurement of adenosine triphosphate in bacteria. The exact mechanisms by which antimicrobials induce the PAE have not been clearly delineated. Animal studies reveal in vivo PAEs in accordance with PAEs obtained in vitro for most organism/ antimicrobial combinations. The clinical relevance of the PAE is probably most important when designing dosage regimens. The presence of a long PAE allows aminoglycosides to be dosed infrequently; the lack of an in vivo PAE suggests that beta-lactam antimicrobials require frequent or continuous dosing. Important questions remain to be answered concerning the PAE.