Critical Care- Jan-March-vol 7 No. 1 by IJCP

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Volume 7, Number 1

January-March April-June 2011

Diagnosis and Treatment of Acute Bronchitis Guidelines for the Prevention of Medication Errors Hemorrhagic Effusions: Comparison of Methods for Better Cytological Assessment Melioidosis with Brain Stem Abscess: A Case Report and Review of Literature International Consensus Group Issues Recommendations for Management of Upper GI Bleeding Acutely Swollen Tongue in a Middleaged Woman Continuous Monitoring of Surgery Patients can Reduce ICU Transfers, Rescue Events

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Asian Journal of

Critical Care Volume 7, No 1, January-March 2011

An IJCP Group Publication Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor

Dr KK Aggarwal CMD, Publisher and Group Editor-in-Chief Dr Veena Aggarwal Joint MD & Group Executive Editor

Contents Contents From the Desk of Group Editor-in-chief

Intensive Care Updates KK Aggarwal

Anand Gopal Bhatnagar Editorial Anchor

review article

Critical Care Editorial Board Dr MM Pandit Rao Prof. Anesthesia, BJ Medical College, Pune Dr Vijay Langer Head, Dept. of Anesthesia, Moolchand Medcity, New Delhi Dr Rajesh Chauhan Sr. Anesthetist, Escorts Heart Institute, New Delhi Dr A Kale Prof. Anesthesia, AIIMS, New Delhi Dr Manju Mani Director-Critical Care, Delhi Heart and Lung Institute New Delhi Dr Tarlika Doctor Associate Professor Anesthesia, BJ Medical College, Ahmedabad Dr Sunita Jain, New Delhi

Diagnosis and Treatment of Acute Bronchitis

Ross H. Albert

clinical practice

Guidelines for the Prevention of Medication Errors

IJCP Editorial Board Dr Alka Kriplani Asian Journal of Obs & Gynae Practice Dr VP Sood Asian Journal of Ear, Nose and Throat Dr Praveen Chandra Asian Journal of Clinical Cardiology Dr Swati Y Bhave Asian Journal of Paediatric Practice Dr Vijay Viswanathan The Asian Journal of Diabetology

clinical study

Hemorrhagic Effusions: Comparison of Methods for Better Cytological Assessment

Preeti, Seema Mittal, Alka

Dr KMK Masthan Indian Journal of Multidisciplinary Dentistry Dr M Paul Anand, Dr SK Parashar Cardiology Dr CR Anand Moses, Dr Sidhartha Das Dr A Ramachandran, Dr Samith A Shetty Diabetology

case report

Dr Ajay Kumar Gastroenterology

Melioidosis with Brain Stem Abscess: A Case Report and Review of Literature

Dr Koushik Lahiri Dermatology

Samit Mehta, B Chendilnathan, Ram Gopalakrishnan,

Dr Georgi Abraham Nephrology

MA Thirunarayan, G Vijaya Kumar

Dr Sidharth Kumar Das Rheumatology Dr V Nagarajan Neurology

practice guidelines

Dr Thankam Verma, Dr Kamala Selvaraj Obs and Gyne Advisory Body Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

International Consensus Group Issues Recommendations for Management of Upper GI Bleeding

Asian Journal of

Review Article

Critical Care Volume 7, No 1, January-March 2011

Contents

Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Pvt. Ltd. and Published at E-219, Greater Kailash, Part-1, New Delhi - 110 048. E-mail: editorial@ijcp.com

photo quiz

Acutely Swollen Tongue in a Middle-aged Woman

Printed at Entire Printers Nampally, Hyderabad ÂŠ Copyright 2011 IJCP Publications Pvt. Ltd. All rights reserved. The copyright for all the editorial material contained in this journal, in the form of layout, content including images and design, is held by IJCP Publications Pvt. Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

news and views

Continuous Monitoring of Surgery Patients can Reduce ICU Transfers, Rescue Events

Editorial Policies The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article.

research review

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Intensive Care Updates

From the desk of Group editor-in-chief Review Article

Dr KK Aggarwal Padma Shri and Dr BC Roy National Awardee Sr Physician and Cardiologist, Moolchand Medcity President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group Editor-in-Chief, eMedinewS Chairman Ethical Committee, Delhi Medical Council Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http://twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)

No Gain with Intensive Glucose Control in ICU There’s no need to use intensive insulin therapy to control blood glucose in hospitalized patients - with or without known diabetes - according to new clinical practice guidelines from the American College of Physicians (ACP). A review of the literature, published in the Annals of Internal Medicine, found intensive insulin therapy did not offer short- or long-term mortality benefits, leading the ACP to recommend against its use to manage hyperglycemia in ICU patients. Spine Repair Effective in Cancer Patients Balloon kyphoplasty reduced pain and improved function in cancer patients with vertebral compression fractures in a randomized trial, researchers said. Roland-Morris Disability scores declined by half after one month in patients undergoing the procedure, whereas those receiving nonsurgical management had almost no change (p < 0.0001), according to James Berenson, MD, of the Institute for Myeloma and Bone Cancer Research in West Hollywood, Calif., and colleagues. The kyphoplasty group also had significant reductions after one month, relative to the control group, in tangible indications of functional status including their need for bed rest, walking aids, bracing, and medications, they reported online in Lancet Oncology. Diet and Exercise go Hand-in-hand for Maintaining Heart Health When it comes to heart health, moderate exercise, not a strenuous workout session, may be the best medicine, no matter what the age group. The stress of a high-intensity workout, said Dr Henry Cusnir, interventional cardiologist at University Hospital and Medical Center in Tamarac, ‘raises blood pressure to levels that are not healthy’ and impose stress on the aorta and heart. n n n Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

Review Article clinical practice

Diagnosis and Treatment of Acute Bronchitis Ross H. Albert

Abstract Cough is the most common symptom bringing patients to the primary care physicianâ&#x20AC;&#x2122;s office, and acute bronchitis is usually the diagnosis in these patients. Acute bronchitis should be differentiated from other common diagnoses, such as pneumonia and asthma, because these conditions may need specific therapies not indicated for bronchitis. Symptoms of bronchitis typically last about three weeks. The presence or absence of colored (e.g., green) sputum does not reliably differentiate between bacterial and viral lower respiratory tract infections. Viruses are responsible for more than 90 percent of acute bronchitis infections. Antibiotics are generally not indicated for bronchitis, and should be used only if pertussis is suspected to reduce transmission or if the patient is at increased risk of developing pneumonia (e.g., patients 65 years or older). The typical therapies for managing acute bronchitis symptoms have been shown to be ineffective, and the U.S. Food and Drug Administration recommends against using cough and cold preparations in children younger than six years. The supplement pelargonium may help reduce symptom severity in adults. As patient expectations for antibiotics and therapies for symptom management differ from evidence-based recommendations, effective communication strategies are necessary to provide the safest therapies available while maintaining patient satisfaction. Key words: Acute bronchitis, rhinorrhea, pneumonia, antibiotics, expectorants

ough is the most common symptom for which patients present to their primary care physicians, and acute bronchitis is the most common diagnosis in these patients.1 However, studies show that most patients with acute bronchitis are treated with inappropriate or ineffective therapies.2 Although some physicians cite patient expectations and time constraints for using these therapies, recent warnings from the U.S. Food and Drug Administration (FDA) about the dangers of certain commonly used agents underscore the importance of using only evidence-based, effective therapies for bronchitis. Diagnosis Acute bronchitis is a self-limited infection with cough as the primary symptom. This infection can be difficult to distinguish from other illnesses that commonly cause cough (Table 1). The common cold often causes coughing; however, nasal congestion and rhinorrhea are also usually present, and a cold typically lasts only seven to 10 ROSS H. ALBERT, MD, PhD, is a hospitalist physician at Hartford (Conn.) Hospital. At the time this article was written, he was a hospitalist at Grand View Hospital in Sellersville, Pa. Source: Adapted from Am Fam Physician. 2010;82(11):1345-1350.

Table 1. Most Common Differential Diagnosis of Acute Cough Acute bronchitis Allergic rhinitis Asthma Chronic obstructive pulmonary disease exacerbation Common cold Congestive heart failure exacerbation Gastroesophageal reflux disease Malignancy Pneumonia Postinfectious cough Postnasal drip Sinusitis Viral syndrome

days. Symptoms of acute bronchitis typically persist for approximately three weeks.3 Pneumonia can usually be ruled out in patients without fever, tachypnea, tachycardia, or clinical lung findings suggestive of pneumonia on examination.4 However, cough may be the only initial presenting symptom of pneumonia in older adults; a lower threshold for using chest radiography should be maintained in these patients. The presence or absence of colored Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

review article (e.g., green) sputum does not reliably differentiate between bacterial and viral lower respiratory tract infections.3 The causative pathogen for bronchitis is rarely identified (Table 25). In clinical studies, identification of the causative pathogen occurs in less than 30 percent of cases.6 Approximately 90 percent of acute bronchitis infections are caused by viruses.7 Because the yield of viral cultures is typically low and results rarely affect clinical planning, routine serologic testing is not recommended for bronchitis. Testing may be considered for influenza when risk is thought to be intermediate and the patient presents within 36 hours of symptom onset. During peak influenza season, testing is generally not helpful because the pretest probability of influenza is high. Conversely, the positive predictive value is too low to be helpful outside of influenza season. Diagnostic testing during outbreaks of bronchitis may also be considered in select clinical scenarios. Mycoplasma pneumonia and Chlamydia pneumonia are bacterial etiologies that can affect young adults. However, trials showing that treatment shortens the course of these infections, even when initiated early, are lacking. Bordetella pertussis, the causative agent in pertussis, can also lead to acute bronchitis. Testing for pertussis should be considered in patients who are unvaccinated; patients with a cough that is paroxysmal, has a â&#x20AC;&#x153;whoopingâ&#x20AC;? sound, or has lasted longer than three weeks; and patients who have been exposed to pertussis or unvaccinated persons. Table 2. Most Common Infectious Etiologies of Acute Bronchitis Viral Adenovirus Coronavirus Influenza A and B Metapneumovirus Parainfluenza virus Respiratory syncytial virus Rhinovirus Bacterial Bordetella pertussis Chlamydia pneumonia Mycoplasma pneumonia Information from reference 5.

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

Treatment Treatment of acute bronchitis is typically divided into two categories: antibiotic therapy and symptom management. Physicians appear to deviate from evidence-based medical practice in the treatment of bronchitis more than in the diagnosis of the condition. Antibiotics

Because of the risk of antibiotic resistance and of Clostridium difficile infection in the community, antibiotics should not be routinely used in the treatment of acute bronchitis, especially in younger patients in whom pertussis is not suspected. Although 90 percent of bronchitis infections are caused by viruses, approximately two thirds of patients in the United States diagnosed with the disease are treated with antibiotics.8 Patient expectations may lead to antibiotic prescribing. A survey showed that 55 percent of patients believed that antibiotics were effective for the treatment of viral upper respiratory tract infections, and that nearly 25 percent of patients had self-treated an upper respiratory tract illness in the previous year with antibiotics left over from earlier infections.9 Studies have shown that the duration of office visits for acute respiratory infection is unchanged or only one minute longer when antibiotics are not prescribed.10,11 The American College of Chest Physicians (ACCP) does not recommend routine antibiotics for patients with acute bronchitis, and suggests that the reasoning for this be explained to patients because many expect a prescription.12 Clinical data support that antibiotics do not significantly change the course of acute bronchitis, and may provide only minimal benefit compared with the risk of antibiotic use itself. A meta-analysis examining the effects of antibiotics in patients with acute bronchitis showed reduction of cough at follow-up (number needed to treat = 5.6) but no change in patientsâ&#x20AC;&#x2122; activity limitations. The meta-analysis also showed a number needed to harm (based on antibiotic adverse effects) of 16.7.13 In a study of 230 patients diagnosed with acute bronchitis (i.e., presence of cough for two to 14 days) who received azithromycin or a low-dose of vitamin C, more than one half of patients had fever or purulent sputum, although none had chest findings. Outcomes at days 3 and 7 were no different between

review article the two groups, and 89 percent of patients in both groups had clinical improvement.14 Although antibiotics are not recommended for routine use in patients with bronchitis, they may be considered in certain situations. When pertussis is suspected as the etiology of cough, initiation of a macrolide antibiotic is recommended as soon as possible to reduce transmission; however, antibiotics do not reduce duration of symptoms. Antiviral medications for influenza infection may be considered during influenza season for high-risk patients who present within 36 hours of symptom onset. An argument for the use of antibiotics in acute bronchitis is that it may decrease the risk of subsequent pneumonia. In one large study, the number needed to treat to prevent one case of pneumonia in the month following an episode of acute bronchitis was 119 in patients 16 to 64 years of age, and 39 in patients 65 years or older.15 Because of the clinical uncertainty that may arise in distinguishing acute bronchitis from pneumonia, there is evidence to support the use of serologic markers to help guide antibiotic use. Two trials in the emergency department setting showed that treatment decisions guided by procalcitonin levels helped decrease the use of antibiotics (83 versus 44 percent in one study, and 85 versus 99 percent in the other study) with no difference in clinical outcomes.16,17 Another study showed that office-based, point-of-care testing for C-reactive protein levels helps reduce inappropriate prescriptions without compromising patient satisfaction or clinical outcomes.18 Symptom Management

Because antibiotics are not recommended for routine treatment of bronchitis, physicians are challenged with providing symptom control as the viral syndrome progresses. Common therapies include antitussives, expectorants, inhaler medications, and alternative therapies. Several small trials and Cochrane reviews help guide therapy for symptom control. The ACCP guidelines suggest that a trial of an antitussive medication (such as codeine, dextromethorphan, or hydrocodone) may be reasonable despite the lack of consistent evidence for their use, given their benefit in patients with chronic bronchitis.12 Studies have shown that dextromethorphan is ineffective for

cough suppression in children with bronchitis.19 These data coupled with the risk of adverse events in children, including sedation and death, prompted the American Academy of Pediatrics and the FDA to recommend against the use of antitussive medications in children younger than two years.20 The FDA subsequently recommended that cough and cold preparations not be used in children younger than six years. Use of adult preparations in children and dosing without appropriate measuring devices are two common sources of risk to young children.21 Although they are commonly used and suggested by physicians, expectorants and inhaler medications are not recommended for routine use in patients with bronchitis.22,23 Expectorants have been shown to be ineffective in the treatment of acute bronchitis.22 Results of a Cochrane review do not support the routine use of beta-agonist inhalers in patients with acute bronchitis; however, the subset of patients with wheezing during the illness responded to this therapy.23 Another Cochrane review suggests that there may be some benefit to high-dose, episodic inhaled corticosteroids, but no benefit occurred with low-dose, preventive therapy.24 There are no data to support the use of oral corticosteroids in patients with acute bronchitis and no asthma. Complementary and Alternative Therapies

Many patients also use nonprescription, alternative medications for relief of their bronchitis symptoms. Studies have assessed the benefits of echinacea, pelargonium, and honey. Trials of echinacea in patients with bronchitis and the common cold have yielded inconsistent results, although studies showing positive results have been modest at best.25 Several randomized trials have evaluated pelargonium (also known as kalwerbossie, South African geranium, or the folk remedy rabassam) as a therapy for bronchitis.26-28 Modest benefits have been noted, primarily in symptom scoring by patients.27 In one randomized trial, patients taking pelargonium for bronchitis returned to work an average of two days earlier than those taking placebo.28 One recent trial examined the effectiveness of dark honey for symptom relief in children with bronchitis compared with dextromethorphan or placebo. Although the authors concluded that symptom scores Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

review article Table 3. Methods for Managing Patient Expectations for Medication to Treat Acute Bronchitis Symptoms Define the diagnosis as a “chest cold” or “viral upper respiratory infection” Set realistic expectations for symptom duration (about three weeks) Explain that antibiotics do not significantly reduce the duration of symptoms, and that they may cause adverse effects and lead to antibiotic resistance Explain that many patients would need to be treated with antibiotics to prevent one case of pneumonia Consider delayed “pocket” prescription or “wait-and-see” prescription* Consider pelargonium to relieve cough in adults *Prescriptions given to patients with instructions to fill them only if symptoms do not resolve within a specific timeframe.

from patients treated with dark honey were superior to those treated with placebo, the clinical benefit was small.29 Reducing Unnecessary Prescribing Many patients with bronchitis expect medications for symptom relief, and physicians are faced with the difficult task of convincing patients that most medications are ineffective against acute bronchitis. Table 3 includes methods that may facilitate these discussions. Careful word selection and communication skills can help reduce antibiotic prescribing.30 For example, one survey showed that patients would be less dissatisfied after not receiving antibiotics for a “chest cold” or “viral upper respiratory infection” than they would be for “acute bronchitis.”30 Another study showed that antibiotic prescriptions were reduced by 50 percent when physicians received communication skills training that focused on eliciting patient expectations of illness and antibiotic use, as well as on educating patients about the natural history of bronchitis.15 “Pocket” prescriptions or “wait-andsee” prescriptions, which are given to patients with instructions to fill them only if symptoms do not resolve within a specific timeframe, have also been shown to reduce antibiotic use.31 Other commonly used methods for addressing patient expectation for antibiotics include providing nonpharmacologic recommendations for symptom management, providing information sheets about viral infections and antibiotics,32 and ensuring close follow-up by phone or with scheduled appointments. Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

References 1. Schappert SM, Burt CW. Ambulatory care visits to physicians offices, hospital outpatient departments, and emergency departments: United States, 2001-02. Vital Health Stat 13. 2006;(159):1-66. 2. Linder JA, Sim I. Antibiotic treatment of acute bronchitis in smokers: a systematic review. J Gen Intern Med. 2002;17(3):230-234. 3. Little P, Rumsby K, Kelly J, et al. Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial. JAMA. 2005;293(24):3029-3035. 4. Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278(17):1440-1445. 5. Wenzel RP, Fowler AA III. Clinical practice. Acute bronchitis. N Engl J Med. 2006;355(20):2125-2130. 6. Boldy DA, Skidmore SJ, Ayres JG. Acute bronchitis in the community: clinical features, infective factors, changes in pulmonary function and bronchial reactivity to histamine. Respir Med. 1990;84(5):377-385. 7. Gonzales R, Bartlett JG, Besser RE, et al.; American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine, Centers for Disease Control, Infectious Diseases Society of America. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med. 2001;134(6):521-529. 8. Linder JA, Sim I. Antibiotic treatment of acute bronchitis in smokers: a systematic review. J Gen Intern Med. 2002;17(3):230-234. 9. Wilson AA, Crane LA, Barrett PH, Gonzales R. Public beliefs and use of antibiotics for acute respiratory illness. J Gen Intern Med. 1999;14(11):658-662. 10. Coco A, Mainous AG. Relation of time spent in an encounter with the use of antibiotics in pediatric office visits for viral respiratory infections. Arch Pediatr Adolesc Med. 2005;159(12):1145-1149. 11. Linder JA, Singer DE, Stafford RS. Association between antibiotic prescribing and visit duration in adults with upper respiratory tract infections. Clin Ther. 2003;25(9):2419-2430. 12. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 suppl):95S-103S. 13. Smucny JJ, Becker LA, Glazier RH, McIsaac W. Are antibiotics effective treatment for acute bronchitis? A meta-analysis. J Fam Pract. 1998;47(6):453-460.

review article 14. Evans AT, Husain S, Durairaj L, Sadowski LS, CharlesDamte M, Wang Y. Azithromycin for acute bronchitis: a randomised, double-blind, controlled trial. Lancet. 2002;359(9318):1648-1654. 15. Petersen I, Johnson AM, Islam A, Duckworth G, Livermore DM, Hayward AC. Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ. 2007;335(7627):982. 16. Christ-Crain M, Jaccard-Stolz D, Bingisser R, et al. Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial. Lancet. 2004;363(9409):600-607. 17. Christ-Crain M, Stolz D, Bingisser R, et al. Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J Respir Crit Care Med. 2006;174(1):84-93. 18. Cals JW, Butler CC, Hopstaken RM, Hood K, Dinant GJ. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ. 2009;338:b1374. 19. Paul IM, Yoder KE, Crowell KR, et al. Effect of dextromethorphan, diphenhydramine, and placebo on nocturnal cough and sleep quality for coughing children and their parents. Pediatrics. 2004;114(1):e85-e90. 20. Use of codeine- and dextromethorphan-containing cough remedies in children. American Academy of Pediatrics. Committee on Drugs. Pediatrics. 1997;99(6):918-920. 21. Lokker N, Sanders L, Perrin EM, et al. Parental misinterpretations of over-the-counter pediatric cough and cold medication labels. Pediatrics. 2009;123(6): 1464-1471. 22. Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev. 2004;(4): CD001831.

23. Smucny J, Flynn C, Becker L, Glazier R. Beta2-agonists for acute bronchitis. Cochrane Database Syst Rev. 2004; (1):CD001726. 24. McKean M, Ducharme F. Inhaled steroids for episodic viral wheeze of childhood. Cochrane Database Syst Rev. 2000;(2):CD001107. 25. Yale SH, Liu K. Echinacea purpurea therapy for the treatment of the common cold: a randomized, doubleblind, placebo-controlled clinical trial. Arch Intern Med. 2004;164(11):1237-1241. 26. Timmer A, G端nther J, R端cker G, Motschall E, Antes G, Kern WV. Pelargonium sidoides extract for acute respiratory tract infections. Cochrane Database Syst Rev. 2008;(3):CD006323. 27. Chuchalin AG, Berman B, Lehmacher W. Treatment of acute bronchitis in adults with a pelargonium sidoides preparation (EPs 7630): a randomized, double-blind, placebo-controlled trial. Explore (NY). 2005;1(6): 437-445. 28. Matthys H, Eisebitt R, Seith B, Heger M. Efficacy and safety of an extract of Pelargonium sidoides (EPs 7630) in adults with acute bronchitis. A randomised, double-blind, placebo-controlled trial. Phytomedicine. 2003;10(suppl 4):7-17. 29. Paul IM, Beiler J, McMonagle A, Shaffer ML, Duda L, Berlin CM Jr. Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med. 2007;161(12):1140-1146. 30. Phillips TG, Hickner J. Calling acute bronchitis a chest cold may improve patient satisfaction with appropriate antibiotic use. J Am Board Fam Pract. 2005;18(6): 459-463. 31. Couchman GR, Rascoe TG, Forjuoh SN. Backup antibiotic prescriptions for common respiratory symptoms. Patient satisfaction and fill rates. J Fam Pract. 2000;49(10):907-913. 32. Macfarlane J, Holmes W, Gard P, Thornhill D, Macfarlane R, Hubbard R. Reducing antibiotic use for acute bronchitis in primary care: blinded, randomised controlled trial of patient information leaflet. BMJ. 2002;324(7329):91-94.

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

clinical practice clinical practice

Guidelines for the Prevention of Medication Errors

Abstract The prevention of medication errors is an essential requirement for pharmaceutical care and must be a core mission of every pharmacy. For medication error prevention efforts to be effective, they must become a priority. Key words: Medication errors, hazardous drug-use situations, Institute for Safe Medication Practices

he first step in setting up an error-reduction program is to establish a multidisciplinary team to improve medication use. The team must be given reasonable time and resources to assess medication safety and implement changes at the system level that make it difficult or impossible for practitioners to make mistakes that reach the patient. This multidisciplinary team should accept ownership of the medication-use process and enthusiastically embrace the opportunity to improve medication safety. The goals of the team should include the following:  Promoting a culture of safety to reduce medication errors;  Increasing detection and reporting of medication errors and potential hazardous drug-use situations;  Exploring and understanding the root causes of medication errors;  Educating practitioners about the system-based causes of errors and their prevention;  Responding to potentially hazardous situations before errors occur;  Recommending methods to facilitate the implementation of organization-wide, systembased changes to prevent medication errors; and  Learning from errors occurring in other organizations through the ISMP Medication Safety Alert! and other published accounts of medication errors, and proactively taking measures to prevent similar errors. Source: Adapted from McMahon Publishing; Pharmacy Practice News, April 2010.

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

Effective results depend on understanding the complex medication-use process as a whole through varied perspectives and disciplines. The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that works closely with health care practitioners and institutions, regulatory agencies, professional organizations, and the pharmaceutical industry to provide education about medication errors and their prevention. ISMP independently reviews medication errors that practitioners have voluntarily submitted to the national Medication Errors Reporting Program. ISMP is an accessible resource for any pharmacist interested in implementing the actions recommended herein. Among the many products and services that ISMP offers is the ISMP Medication Safety Alert! Acute Care Edition, a biweekly newsletter that provides timely information related to error prevention. It identifies errors that have been reported by other organizations and offers recommendations to prevent those errors from occurring in the pharmacy. The information in Tables 1 to 4 of this review summarizes many of the significant error-prevention strategies that were recommended in the ISMP Medication Safety Alert! Acute Care Edition during the past 12 months. The errors presented in the tables are actual or potential errors reported to ISMP. Each table consists of 4 columns. The first column lists the medications, devices, or other problematic issues involved. The second column describes the specific error or problem involved. The third column addresses ISMP’s recommendations to proactively 11

clinical practice Table 1. Safety Issues Related to Labeling, Packaging, and Nomenclature Medication

Problem

Recommendation(s)

Technology

CETACAINE (benzocaine 14%, butamben 2%, tetracaine hydrochloride 2%; Cetylite Industries) bottles with Luer connector

Cetacaine liquid, a local anesthetic that is not suitable for injection, is available in a bottle with a dispenser cap that is compatible with any Luerlock syringe.

Avoid using this form of Cetacaine if there is a possibility it may end up in an area where parenteral injections are administered.

None

Color-coded eye medications

Bausch and Lomb’s atropine sulfate 1% and cyclopentolate 1% ophthalmic drops look nearly identical, which led to an error.

Avoid awarding contracts to one vendor for an entire ophthalmic product line.

2, 4

The ability to draw the liquid into a parenteral syringe and the potential for unlabeled syringe mix-ups is a cause for concern in settings where parenteral injections are administered.

Mix-ups also have occurred between polymyxin B and trimethoprim ophthalmic solution, and neomycin, polymyxin B, and gramicidin solution.

Purchase products within a class from different manufacturers.

The products are color-coded by pharmacologic class, making all products within a class the same color. DEPAKOTE ER (divalproex sodium extended release; Abbott) and DEPAKOTE (divalproex sodium delayed release; Abbott) mix-up Dosage strengths that differ by a factor of 10

A physician wrote a prescription for generic Depakote ER as “divalproex ER.” Later when a community pharmacist typed in the generic name, “divalproex EC” appeared on the computer screen. The pharmacist then selected and dispensed “divalproex EC” to the patient. “Divalproex EC” actually refers to the entericcoated or delayed-release form of divalproex and can be given up to 4 times a day, whereas Depakote ER is available as a once-daily formulation. A common type of dosing error involves mix-ups between drug dosage strengths that differ by a factor of 10. For example, ISMP has received several error reports in which 20 mg of ABILIFY (aripiprazole; Bristol-Myers Squibb) was accidentally dispensed to patients instead of 2 mg. In one case, a 7-yearold child took 68 doses that were 10 times higher than the prescribed dose.

Educate staff about the difference in dosing frequency between these 2 products.

1, 2, 4, 5

If possible, add a computerized alert to remind staff about the potential for mix-up. When repeating back oral orders, use full words (eg, extended release) not abbreviations. Separate storage and use auxiliary warning labels to differentiate the products. • Avoid using naked decimals (eg, write 0.5 mg 1, 2, 4, 5 instead of 0.5 mg) and trailing zeros (e.g., write 2 mg instead of 2.0 mg) on all prescriptions (written and electronic), computerized medication selection screens, and preprinted order forms.

The use of trailing zeros (i.e., 5.0 mg) and naked decimal points (i.e., .5 mg) increases the risk for a 10-fold dosing error. FER-IN-SOL (ferrous sulfate drops; Mead Johnson Nutritionals) concentration change

Generic methylergonovine (PharmaForce) and PITOCIN (oxytocin; JHP Pharma)

In mid-2008, Mead Johnson Nutritionals changed the concentration of Fer-In-Sol from 15 mg of elemental iron/0.6 mL (25 mg/mL) to 15 mg of elemental iron/mL; however, little was done to inform the public or health care providers about the change. Iron drops from other manufacturers still use the 15 mg of elemental iron/0.6 mL concentration. 



A newly approved (1 mL) vial of methylergonovine maleate is available from PharmaForce with a cap that is the same shade of green as Pitocin (oxytocin) vials, available from JHP Pharma. Both drugs are found on obstetrical units; a mix‑up would be disastrous.

Stock a standard concentration of iron drops, 1, 5 and be sure the formulary and drug indexes list the correct concentration. Require all orders to be written in milligrams (mg) of iron, never by volume alone. Always verify the concentration of iron in the product being dispensed and administered as well as the volume needed to provide the intended dose. 

Until a change in cap color occurs, avoid storing these 2 products together on obstetrical units.

2, 4

(Cont’d...)

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

clinical practice ...Table 1. Cont’d Medication Heparin 40,000 unit vials

Problem 



Hospira minibags of concentrated potassium chloride



IV promethazine



The label on heparin 4 mL (10,000 units/ mL) vials highlights the 10,000 units/mL concentration, not the total dose. The total dose (40,000 units) can easily be missed, which could lead to the misconception that the vial holds a total of 10,000 units. This could lead to a serious overdose. Potassium chloride 10 mEq in 100 mL (100 mEq/L) minibags were placed in an ADC in a compartment intended for 10 mEq in 50 mL (200 mEq/L) minibags, which led to a mix-up. The concentrations and volumes can be easily missed on the label. In September 2009, the FDA announced a requirement for stronger manufacturer warnings regarding severe tissue damage associated with accidental intra-arterial administration or extravasation of IV promethazine.

Recommendation(s)  

 



 

LOVAZA (omega-3-acid ethyl esters; GlaxoSmithKline)



PENTACEL



(diphtheria and tetanus toxoids, acellular pertussis [DTaP], inactivated poliovirus [IPV], and Haemophilus b [Hib] conjugate; Sanofi Pasteur) Unlabeled EPINEPHrine syringe

A nurse punched holes in a Lovaza gelatin capsule and squeezed the contents into a foam plastic cup, then noticed that the bottom of the cup dissolved within minutes. No warnings appear in the product labeling. The same problem is associated with nonprescription omega-3 products. The effect on plastic oral syringes and toxicity from dissolved plastics is unknown. Pentacel is a 2-vial vaccine product that requires mixing of the 2 components before administration. Only the DTaP/IPV vial carries the brand name Pentacel. Clinicians may think only the vial labeled Pentacel is needed.

 



 



A patient died after receiving an injection of EPINEPHrine 1:1,000 from an unlabeled syringe that a surgical nurse and surgeon thought contained a local anesthetic. EPINEPHrine for topical use was on back order, so the nurse withdrew the contents of a vial of the injectable product into a syringe. The syringe was mistaken as the local anesthetic.



   

Technology

Evaluate whether your facility needs heparin vials that contain 40,000 units. When possible, stock only a 1 mL vial of heparin 10,000 units/mL.

2, 4, 5

Separate the storage of these products in the pharmacy and patient care units. Use auxiliary stickers on the bags to make the concentration more visible and to help differentiate the 2 concentrations. Consider stocking only 1 concentration of potassium chloride minibags.

2, 4

If possible, remove promethazine from the formulary and use alternatives such as 5-HT3 antagonists (eg, ondansetron) when appropriate. If you MUST keep promethazine on the formulary, administer it by deep intramuscular injection only. Avoid IV use. Build alerts to appear on CPOE systems, MARs, and ADC screens. Additional recommendations can be found at www.ismp.org.

1, 5

Place Lovaza and other omega-3 products on your facility’s “do not crush” list. When these drugs are prescribed, add specific warnings to MARs.

Educate staff who will be administering vaccines to children about the need to mix the 2 vials. If feasible, have pharmacy add auxiliary labeling to the product before dispensing it. Require that the NDC number, lot number, and expiration date for each component be documented in the vaccine log.

None

Supply EPINEPHrine for topical use only in None the manufacturer’s or pharmacyprepared pour bottles. Never withdraw a topical product into a parenteral syringe. Keep local anesthetics for injection in their original vials until they are ready to be used. Label all syringes. Use presoaked EPINEPHrine pledgets when feasible

ADC = Automated dispensing cabinet; CPOE = Computerized prescriber order entry; MAR = Medication administration record; NDC = National Drug Code.

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

clinical practice Table 2. Safety Issues Associated with Order Communication Communication KAPIDEX (dexlansoprazole; Takeda) and

Problem 

CASODEX (bicalutamide; AstraZeneca)

LYRICA (pregabalin; Pfizer) and LOPRESSOR (metoprolol tartrate; Novartis) mix-up Order TAMIFLU (oseltamivir; Roche) oral suspension in milligrams (mg)

Name mix-ups involving PROVERA (medroxyPROGESTERONE; Pfizer), PROZAC (FLUoxetine; Eli Lilly), and PROSCAR (finasteride; Merck) Quinine and quinidine

U looks like 4



A patient was admitted to a hospital with an order for Lopressor 100 mg twice daily. The physician’s handwriting was poor, and the order was misinterpreted and dispensed as Lyrica 100 mg twice daily. The Tamiflu product label recommends prescribing doses in milligrams (mg), which corresponds with the oral syringe in the Tamiflu box that is marked in increments of 30, 45, and 60 mg. Many prescribers, however, order liquid medications by volume (i.e., mL or teaspoons), which makes it impossible to measure the dose using the oral syringe that comes with the drug. A pharmacist misread a handwritten order for Provera 10 mg PO daily and dispensed Prozac 10 mg. The handwritten order was shown to several nurses, pharmacists, and physicians; one person thought the order was for Proscar.



Text messaging language used

Numerous errors have been reported due to name confusion between Kapidex and Casodex with both handwritten and verbal prescriptions.

Recommendation(s)



A physician ordered QUALAQUIN (quinine sulfate; AR Scientific) 324 mg for leg cramps for a newly admitted patient. The pharmacist selected a 324 mg tablet from a list of products on the computer screen. However, he selected quinidine extended release 324 mg instead of quinine. This error continued for almost 2 weeks until a consulting physician wondered why this patient was on such a low dose of quinidine. The medication was then stopped. The patient never complained of leg cramps. A pharmacist questioned whether an order for magnesium chloride 64 mg TID “2Day” meant to give the drug TID for 2 days or to give it “today” (2Day). It turned out “2Day” was “text messaging” shorthand for “today.” A handwritten order for NOVOLOG was misread as “54 units” instead of the intended “5 units.” The word “Units” had been written out, but the capital letter “U” looked like the number “4,” and the remaining part of the word, “nits,” was read as “units.”



Technology

Consider adding Kapidex and Casodex to your list of look-alike drug names. Build software alerts to warn about possible confusion. Require prescribers to include the drug’s purpose on prescriptions. Takeda Pharmaceuticals has announced that it will change the name from Kapidex to Dexilant.

1, 2, 4, 5

Consider adding a computer alert about this newly reported look-alike drug name pair. Match the drug’s indication to the patient’s disease state to help avoid mix-ups between products with look-alike names.

1, 2, 4, 5

Remind prescribers that they need to prescribe Tamiflu doses in milligrams if the measuring device that comes with the drug is to be used. If pharmacists receive prescriptions with volume doses, they should clarify the dose with the prescriber and ensure that the pharmacy label matches the way the drug will be measured.

1, 5

Consider adding these drugs to your list of look-alike drug names. Build software alerts to warn about possible confusion between these drugs. Require that prescribers include the drug’s purpose on orders. Require staff to match the prescribed drug with the patient’s medical history.

1, 2, 4, 5

Quinine should not be available for leg cramps and should be removed from the formulary. If malaria (the only approved indication for quinine) is encountered, access the drug from an outside source. Use tall man letters for quiNIDine and stock it only in the available 300 mg strength (extended release and immediate release).

1, 2, 4, 5

Text messaging language is not appropriate for writing or transcribing medical orders due to potential misinterpretation.

Maintain adequate space between the numerical dose and unit of measure when handwriting medication orders. Electronic prescribing would also reduce the risk for misinterpreting handwritten orders.

(Cont’d...)

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

clinical practice ...Table 2. Cont’d Communication

Problem

VALTREX (valacyclovir; GlaxoSmithKline) and VALCYTE (valganciclovir; Roche)

 



Verbal order error with sound-alike drug names



Mix-ups continue to occur between Valtrex and Valcyte. The generic names for these 2 drugs are strikingly similar, and both the brand and generic names of the products start with the prefix “val.” Both have uses associated with cytomegalovirus and may be used in immunosuppressed patients with HIV and transplant patients. A physician phoned in an order for an ampule of naloxone to treat a patient for respiratory depression. A nurse, however, heard “LANOXIN” and prepared and administered a dose of Lanoxin (digoxin; GlaxoSmithKline) from unit stock. After repeated doses of what was thought to be naloxone were given, the error was discovered. The patient subsequently died.

Recommendation(s)  

 

  

Technology

Consider adding these drugs to your list of look-alike drug names. Use tall man letters—valACYclovir and valGANCIclovir—when listing the drugs in computerized inventories. Build software alerts to warn about possible confusion. Use both the brand and generic names when prescribing or listing these drugs.

1, 2, 4, 5

Encourage nurses to read back or at least repeat back verbal orders. Prescribe in metric weight doses (i.e., mg), not in ampules. Clarify incomplete orders that do not include the dose in metric weight.

Table 3. Problems Involving Drug Information, Patient Information, Staff Education, and Patient Education Information Acute hyponatremia in children

Problem 



Anesthesia Patient Safety Foundation recommendations for safe postoperative opioid use

Basal opioid infusions with PCA therapy



Two 6-year-old children died after staff failed to recognize the signs of severe postoperative hyponatremia. In one case, the rapid administration of plain D5W (dextrose 5% in water) postoperatively resulted in free water retention (also called water intoxication). In another case, a child received several doses of furosemide and EDECRIN (ethacrynic acid; Aton Pharma), exacerbating the loss of sodium. Children who receive hypotonic solutions are vulnerable to water intoxication because they are prone to developing SIADH or the excessive release of ADH. The Anesthesia Patient Safety Foundation recently published an editorial regarding the continuing problem of opioid-induced respiratory depression. The Foundation identified inadequate monitoring of oxygenation and/or ventilation, in addition to failure to consider patient-specific characteristics, as causes for the continued occurrence of opioidinduced respiratory depression.

An opioid-naïve patient with sleep apnea was started on HYDROmorphone PCA with a basal infusion. She experienced respiratory depression and became unresponsive. The PCA order form prompted for a basal infusion without a screening process to determine whether patients were appropriate candidates. The American Pain Society cautions against using continuous basal infusions because studies have failed to demonstrate significant differences in the quality of analgesia with or without basal infusions.

Recommendation(s) 



Do not administer hypotonic saline or parenteral fluids without saline; it is physiologically unsound and potentially dangerous for hospitalized children. Standards of practice should be established for postoperative IV solutions used to hydrate patients, particularly children. Protocols should be established to identify, treat, and monitor patients who have hyponatremia, water intoxication, and/or SIADH.

Technology 1, 5

The Foundation recommends that the following be addressed in all patients receiving postoperative opioids: 1. Individualize each patient’s dose based on the patient’s history and physical status; 2. Make pulse oximetry routine; 3. Assess each patient’s need for supplemental oxygen; and 4. Consider capnography to monitor ventilation, particularly for patients who are receiving oxygen and/or are at high risk for opioid-induced respiratory depression Establish risk factors and screening criteria 1, 5 for basal infusions and avoid basal infusions for patients with sleep apnea and patients who are not opioid-tolerant. Establish special monitoring requirements (eg, pulse oximetry/capnography, frequent assessment in the first 24 hours and at night) for any patient who receives a basal infusion.

(Cont’d...) Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

clinical practice ...Table 3. Cont’d Information Documenting a true allergy or other adverse symptoms

Problem 



HYDROmorphone dosing

 

Insulin concentration



Methotrexate dosing

Transdermal patches worn during MRIs



VIAGRA (sildenafil; Pfizer) and REVATIO (sildenafil; Pfizer)

Weights should be in kilograms (kg) only



An elderly patient for whom codeine was listed as an “allergy”—when it really only made him sleepy— received DARVOCET-N (propoxyphene napsylate, acetaminophen; Xanodyne) postoperatively while he was also taking carbamazepine. The patient died 2 days later from carbamazepine poisoning. Propoxyphene may decrease the metabolism of carbamazepine, thereby increasing the serum concentration of the drug. A 40-year-old opioid-naïve man died after receiving 3 injections of HYDROmorphone 2 mg IV in 9 hours. His wife mentioned that, previously, the patient had not tolerated VICODIN (acetaminophen and HYDROcodone; Abbott). A patient received 100 units instead of 10 units of regular insulin IV for the treatment of hyperkalemia. An anesthesiology resident drew 1 mL of U-100 insulin into a 10-mL syringe, added 9 mL of saline, and injected the entire contents. Inadequate hospital orientation and training of residents in medication preparation was a key contributing factor. Before hospital admission, a patient with rheumatoid arthritis had been taking oral methotrexate 10 mg twice a day, one day each week. On the discharge medication list, the drug was erroneously transcribed as “methotrexate 10 mg PO twice daily.” The patient took the drug every day and had to be readmitted for treatment of serious side effects.

The FDA issued a public health advisory in March 2009 regarding transdermal patches worn during MRI tests. Some patches are formulated with an aluminized backing or invisible metal layer that could cause excessive heat and tissue damage to the patient if worn during MRI testing. An emergency department patient with chest pain told the doctor she was taking Revatio for primary pulmonary arterial hypertension. The physician did not know Revatio was sildenafil, so he treated her with nitroglycerin (sublingual and IV), which is contraindicated in patients taking sildenafil. The problem was soon recognized and the infusion was stopped. The patient experienced no adverse effects or blood pressure changes. A pharmacist was consulted to visit a patient for CUBICIN (DAPTOmycin; Cubist) dosing. The pharmacist noticed that the patient’s weight had been entered into the computer as 150 kg instead of 150 lb. The person entering the weight failed to convert pounds to kilograms after weighing the patient on a scale that measured weight in pounds.

Recommendation(s) 



Technology

When communicating an allergy or a non-life-threatening drug reaction, health professionals should always include a description of the reaction. Forms should prompt for this information. Some computers offer pull-down menus from which to select the most appropriate reason for listing the problematic drug.

1, 5

Always document the type of reaction the patient has experienced in response to a problem drug. Opioid-naïve patients should not receive high initial doses of opiates, especially HYDROmorphone; 2 mg IV is equivalent to approximately 12-14 mg of IV morphine.

1, 5

Develop a medication preparation course None and preceptor program for new residents and anesthesia, OR, PACU, and pharmacy staff. In hospitals with OR pharmacy satellites, insulin dilution and dose preparation should occur in the satellite pharmacy, or an insulin minibag system (prediluted to 1 unit/mL) may be used. Before discharging patients, medications on the discharge list should be reconciled with the list provided at admission, and discrepancies should be resolved. Patients discharged on methotrexate should receive instructions emphasizing the weekly dosing schedule. They also should receive a follow-up phone call 1 or 2 days after discharge to ensure they understand those instructions.

None

Patients prescribed transdermal medication should be educated to remove the patch temporarily when undergoing MRI tests. Facilities should follow published recommendations concerning patients who wear patches and undergo MRI tests.

None

Health professionals can reduce the risk for errors by reviewing readily accessible drug information if they encounter unfamiliar products. Encourage patients who take Revatio to note on their medication list that the drug is also marketed as Viagra.

1, 5

Weights should always be based on the metric system, and scales should always provide the weight in kilograms. Preprinted order sets, protocols, guidelines, and computer screens should prompt only for kilogram weights.

1, 5

ADH = Antidiuretic hormone; MRI = Magnetic resonance imaging; OR = Operating room; PACU = Postanesthesia care unit; PCA = Patient-controlled analgesia; SIADH = Syndrome of inappropriate antidiuretic hormone.

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

clinical practice Table 4. Medical Devices and Other Discussion Items Title Baxa Corporation compounder alert

Borrowing medications

Problem/Discussion Point 



In March 2009, Baxa issued a safety alert on its Exacta-Mix 2400 Compounder to warn users that interacting with the touch-screen while the pump door is open may cause an inaccurate ingredient delivery. If the user presses the “RESUME” button while the door is open and the compounder is pumping or alarming, an overdelivery of an individual ingredient will result. Often practitioners are tempted to borrow a medication from another patient’s cassette, from a discharged patient’s unused medications, or from another patient care unit to speed the process of administering an unavailable dose to their patient. This workaround increases the risk for an error and potential harm to the patient.

Recommendation 



Inattentional blindness



When someone fails to see what should have been plainly visible—a warning sticker on a medication label, for example—the cause is usually rooted in inattentional blindness, a condition all people exhibit periodically.



Independent double-checks

ISMP Medication



Safety SelfAssessment for ADCs

The value of independent double-checks has yet again been called into question. Some believe the process is not justified and could lead to more mistakes, whereas others feel that it does not work. When performed correctly, however, double-checks can identify a relatively high rate of errors, because confirmation bias often can block a person’s ability to see his or her own mistakes. More than 80% of US hospitals have implemented ADCs, making the evaluation of practices surrounding this technology an essential step in ensuring patient safety.



 

ON-Q Painbuster elastomeric pump (I-Flow)



   

Safety issues have been identified with the ON-Q PainBuster, an elastomeric pump used to provide pain relief after surgery. The pump usually is filled and started in the OR without pharmacy involvement or knowledge. Patients with the pumps have arrived on units where nurses have never seen the pump. The medication reservoir ball of the ON-Q pump has been found unlabeled. Infusion rates may vary because of over- or under-filling of the balls; we’ve received one report of premature emptying of the pump.



 



Technology

Communicate this information to all pharmacy personnel, and reinforce the need to close the pump door before pressing “RESUME.” Pharmacy staff who check bags after production should also check the MixCheck Report for any bubble or occlusion alarm, and ensure the proper steps were followed. Baxa has provided a warning label for the compounder.

None

Remedy the reasons for borrowing, which often are rooted in system deficiencies or misconceptions about the clinical significance of quick administration. Ensure that nurses understand the risks associated with borrowing medications; ensure that pharmacists understand the risks of delayed order review and dispensing. Educate staff about how to safely resolve “missing medications.”

Increase the conspicuity of critical information on 1, 2, 3, 4, 5 product labels, computer screens, MARs, and other sources of information, by using a high degree of contrast with the background. Ensure that those who need the critical information you are providing perceive it as relevant. Decrease multitasking and diversion of attention during complex tasks. For double-checks to be effective, they must be accomplished independently; provide education to staff regarding the appropriate method. Double-checks also should be limited to certain high-alert medications, very complex processes, and high-risk patient populations. Staff should document and report mistakes caught during the checking process, and they should analyze and act on these reports.

None

To help assist organizations, ISMP has introduced a Medication Safety Self-Assessment for ADCs. The self-assessment should be used by all hospitals that use ADCs. This tool and instructions on how to use it are available at www.ismp.org.

None

Establish standard order sets for prescribing this pump and specific medications. Allow use of local anesthetics only. ON-Q pumps should be prepared only in the pharmacy, except in urgent situations. The pharmacy should use a protocol that specifies the exact amount of solution to instill in the reservoir, based on the duration of therapy. Always label the pump (drug, concentration, infusion rate, start date).

None

(Cont’d...)

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

clinical practice ...Table 4. Cont’d Title

Problem/Discussion Point

Oral syringes



Order management scanning systems



Recommendation

Patients continue to be subjected to risk when oral/enteral products are prepared and administered in parenteral syringes, which can inadvertently be connected to an IV line. Oral syringes have specially engineered hubs that cannot be easily or securely connected to IV lines or accommodate a needle. The latest victim of such an error was a newborn who died after an intermittent feeding prepared in a parenteral syringe was administered IV instead of via a nasogastric tube. Order management scanning systems offer numerous advantages, but if the pharmacy never receives certain orders—such as when multiple pages of orders are pulled through the scanner at the same time and only the top page is scanned—these benefits can be compromised.



Scan the label on the vial itself

Sharing insulin pens



A vial of generic sulfamethoxazole and trimethoprim injection was accidentally placed in a bin for EPINEPHrine injection. A technician took this vial from the EPINEPHrine bin and scanned the label on the bin, not the vial itself. The vial was placed in a plastic baggie with a bar-code label. A pharmacist checked the item by scanning the bar code on the plastic bag, not the vial. A technician then placed the item in an ADC, again scanning only the plastic bag. While performing a monthly ADC check, a pharmacist discovered the error and removed the erroneous vial. An army hospital announced that 2,114 insulin-dependent diabetic patients may be at risk for developing a blood-borne disease because insulin pens were reused for multiple patients. Even when a new needle is placed on the pens before each use, cross-contamination is still possible.



Withdrawing insulin from a pen



Nurses at a hospital were drawing insulin doses out of pen cartridges with an insulin syringe. This practice can introduce air into the cartridge, leading to inaccurate dose measurement when the pen is used, and may also risk contamination of the remaining medication in the pen.



Technology

Use parenteral tubing with ports that are incompatible with oral syringes, and enteral devices that only accommodate oral syringes and catheter tip connectors. Supply all areas with oral syringes and dispense oral liquids from the pharmacy in oral syringes. Require that pharmacy be notified if liquid medications are required. Apply auxiliary labels to oral syringes and label all access lines.

None

Remove staples, open creases, number each None page, and scan one page at a time. Require the sender to verify the number of pages scanned. Perform end-of-shift chart checks comparing the original order to the pharmacy-generated MAR. Review drug therapy during handoffs. To prevent mix-ups of products, scan the None product label itself when removing drugs from bins, ADCs, or carousels. Drug storage bin labels should never be used to identify products.

Facilities using insulin pens should act None immediately and provide education and continuous monitoring to prohibit situations in which an individual patient’s pen might be reused for another patient. Labeling each dispensed pen with the patient’s name helps to reinforce that the pen is intended for that patient alone. If safe use of pen devices can’t be assured at an institution, the devices should not be used there. Provide education and guidelines on how to correctly use the insulin pens available in the hospital and why insulin should not be withdrawn from pen cartridges and used as small insulin vials.

None

ADCs = Automated dispensing cabinets; ADH = Antidiuretic hormone; MAR = Medication administration record; OR = Operating room.

Cont’d on page 28...

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

clinical study clinical practice

Hemorrhagic Effusions: Comparison of Methods for Better Cytological Assessment Preeti*, Seema Mittal**, Alka*

Abstract Aim: To find out the utility of Carnoy’s fixative, glacial acetic acid (GAA) and normal saline rehydration technique (NSRT) in treatment and fixation of smears and to determine the most effective technique for improving the quality of smears and for better cytological assessment in hemorrhagic effusions. Material and methods: Total 150 hemorrhagic samples were studied. Four smears were made from each sample, out of which three smears were subjected to lysing agents viz. Carnoy’s fixative, GAA and NSRT. The fourth smear was wet fixed and used as a control. All the smears were stained with Papanicolaou stain. Observation: NSRT showed lysis of RBCs in 91.33% cases followed by Carnoy’s technique in 82% cases and GAA in 53.33% cases. 86.65% cases showed retention of epithelial/mesothelial cells with NSRT followed by Carnoy’s technique in 72% cases and by GAA in 56.6% cases. Cytological features were best preserved with Carnoy’s technique accounting for 77.3% cases followed by GAA in 68% cases. P value was <0.01 and was significant. Conclusion: The most effective method for RBC lysis in smear background and cell retention is NSRT. Nuclear and cytoplasmic characters are best preserved with Carnoy’s fixative. Key words: Hemorrhagic effusions, normal saline rehydration technique, Carnoy’s fixative, glacial acetic acid

spiration of serous cavities is a simple and relatively noninvasive technique to achieve a diagnosis. The diagnostic performance of the cytologic study of the fluid may be attributable to the fact that the cell population present in the sediment is representative of a much larger surface area than that obtained by needle biopsy.1,2 Cytologic methods have been used for the body fluids to diagnose neoplastic as well as non-neoplastic disorders.3 Many effusions are blood stained, and most of it point to malignant pathology.4-6 However, hemorrhagic diathesis, trauma and rarely tuberculosis can also be the underlying cause.7,8 Presence of RBCs partially or completely obscures the morphological details of cells in the fluid, thus making it difficult to study and to give accurate diagnosis on such smears.9 Many reagents and methods are suggested to lyse RBCs in the background of the smears prepared from hemorrhagic fluids. The present study has been undertaken to find out the utility of Carnoy’s fixative, glacial acetic acid (GAA) and *Dept. of Pathology Adesh Institute of Medical Sciences and Research, Bathinda **Dept. of Pathology, General Hospital, Sirsa Address for correspondence Dr Preeti Dept. of Pathology Adesh Institute of Medical Sciences and Research Barnala Road, Bathinda, Punjab - 151 109 E-mail: dr_priti77@yahoo.com

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

normal saline rehydration technique (NSRT) in treatment and fixation of smears and to determine the most effective technique in improving the quality of smears of hemorrhagic effusions for better cytologic assessment. Material and Methods Our prospective study was conducted from January 2009 to December 2009. One hundred fifty hemorrhagic samples were received in the cytology section of the Dept. of Pathology in our institution. Gross examination of fluid in terms of types of fluid volume and color was done. Four smears were made from each hemorrhagic fluid sample after centrifugation at 2000 rpm for 10 minutes. First smear was wet fixed, without hemolysis and was used as a control. Other three smears were subjected to hemolysis by Carnoy’s fixative, GAA and NSRT. Papanicolaou stain was done on all four smears. The smears were then compared with control regarding RBC lysis in the smear background, retention of epithelial cells/ mesothelial cells and cytological preservation. Scores 1-4 were allocated for each smear based upon scoring system given by Ng et al.10 Smear background was scored as score 1 (nonhemolyszd RBCs), score 2 (approximately 75% 19

Clinical Study non-hemolyzed RBCs), score 3 (approximately 50% nonhemolyzed RBCs) and score 4 (approximately 25% nonhemolyzed RBCs). Retention of epithelial/ mesothelial cells was scored as score 4 (same as control smear), score 3 (approximately 75% retention), score 2 (approximately 50% retention) and score 1 (approximately 25% retention). Nuclear and cytoplasmic features were considered for cytological preservation of the smears and were scored as score 4 (excellent preservation), score 3 (optimal preservation), score 2 (suboptimal preservation) and score 1 (very poor preservation). All values were interpreted statistically using Chisquare test. All results were analyzed considering statistical significance at a level of p = 0.05.

The effect of lysing agents on background of the smear was studied and compared with control smear (Fig. 1). Best effect out of all the techniques with score 4 was obtained by NSRT in 91.33% cases (Fig. 2) followed by Carnoy’s technique (CY) in 82% and GAA in 53.33% cases (Fig. 3) (Table 2). The p value was <0.01 and was significant. The effect on retention of epithelial/mesothelial cells was best observed with NSRT with 86.65% cases having scored 4 (Fig. 2) followed by Carnoy’s technique 72.02% cases and by GAA in 56.65% cases (Table 3). The p value was <0.01 and was significant. Table 2. Effect of Lysing Agents on Smear Background Method

Observations

Score 1

Score 2

Score 3

Score 4

Total

One hundred fifty samples of hemorrhagic effusions were studied. 50.66% cases were that of pleural effusion. 46.67% and 2.67% cases were of peritoneal and pericardial fluid, respectively (Table 1).

1 (0.67%) 6 (4.0%)

GAA

1 (0.67%) 17 (11.33%) 52 (34.67%) 80 (53.33%) 150

Table 1. Distribution of Cases According to Site of Effusion

Table 3. Effect of Lysing Agents on Retention of Epithelial/Mesothelial Cells

NSRT

4 (2.67%)

Method

20 (13.33%) 123 (82.0%) 150

9 (6.0%)

137 (91.33%) 150

Number of cases

Types of effusions

No. of cases

Pleural

76 (50.66%)

Peritoneal

70 (46.67%)

Pericardial

04 (2.67%)

GAA

Total

150 (100%)

NSRT

Figure 1. Photomicrograph of smear from ascitic fluid showing malignant epithelial cells with marked blood in the background. (Papanicolaou stain on wet fixed smear, 200x).

Number of cases

Score 1

Score 2

Score 3

Score 4

Total

1 (0.68%) 1 (0.68%) 40 (26.62%) 108 (72.02%) 150 4 (2.70%) 61 (40.65%) 85 (56.65%) 150 -

20 (13.35%) 130 (86.65%) 150

Figure 2. Photomicrograph of smear from pleural fluid showing excellent retention of malignant epithelial in clean background (Papanicolaou stain after treatment of smear with normal saline rehydration technique, 400x).

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

Clinical Study

Figure 3. Photomicrograph of smear from ascitic fluid showing average cytological preservation of mesothelial cells against a dirty background. (Papanicolaou stain after treating the fluid with glacial acetic acid, 200x).

Figure 4. Photomicrograph of smear from ascitic fluid against a clean background with reactive mesothelial cells showing sharp nuclear and cytoplasmic margins. (Papanicolaou stain after treating the smear with Carnoy’s fluid, 400x).

Table 4. Effect of Lysing Agents on Cytological Preservation

smear. In another study, almost complete lysis of RBCs was seen in 93% cases.9 Gupta et al11 observed that RBCs were seen in only 3% of rehydrated smears compared to 12% of the total in wet fixed ones and concluded that smear background was cleaner in saline rehydrated technique.

Method

Number of cases Score 1 Score 2

Score 3

Score 4

Total

4 (2.67%) 30 (20.0%) 116 (77.33%) 150

GAA

5 (3.33%) 43 (28.67%) 102 (68.0%)

150

NSRT

3 (2.0%) 77 (51.33%) 70 (46.67%)

150

The cytological preservation was best seen with Carnoy’s technique in 77.33% cases (Fig. 4) followed by GAA in 68% cases and NSRT in 46.67% (Table 4). The p value was <0.01 and was significant. Discussion Hemorrhagic effusions lead to great diagnostic difficulties. Only few studies have been undertaken to improve the quality of smears in hemorrhagic effusions. The aim of the present study was to assess and to compare the efficacy of NSRT, GAA and Carnoy’s fixative to lyse the RBCs, to preserve epithelial/mesothelial cells and to retain the cellular morphology in hemorrhagic effusions. Total 150 cases of hemorrhagic effusions were included in the study; 50.66% pleural fluid; 46.67% peritoneal fluid and 2.67% pericardial fluid. Malvi and Anthony9 reported 76.65% pleural, 20% peritoneal and 3.3% pericardial fluids in their study. In our study, almost complete lysis of RBCs occurred in 91.33% cases with NSRT as compared to control Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

In our study, epithelial/mesothelial cell retention was same as in wet fixed smear in 86.65% cases with NSRT. Ng et al10 observed the retention of epithelial/ mesothelial cells in 78% cases with rehydration technique. Excellent cytological preservation with NSRT was seen in 46.67% cases while in 51.33% cases it was optimal for diagnosis. Other authors reported that air dried rehydrated smears had significantly better cytological feature as compared to wet fixed smears.10,12,13 In our study, on treatment of fluids with GAA, 53.33% cases of the total samples had a clear background as compared to wet fixed smears. In 46.67% of the smears lysis was not complete and the background was dirty. This observation is similar to study by Malvi and Anthony9 wherein they found 50% of the smears with partial lysis of RBCs on treatment with GAA. In 56.65% cases epithelial/mesothelial were retained as in wet fixed smears. Cytological features were excellent in 68% cases and this is similar to another study.9 Reprocessing of hemorrhagic cervicovaginal smears with GAA resulted in change within the range of 56.65-62% cases from unsatisfactory to satisfactory described in literature.14,15 21

Clinical Study In the present study, processing of fluid with Carnoy’s technique showed 82% cases with complete lysis of RBCs. Epithelial/mesothelial cells were retained in 72% of cases. This is in variance with other study,9 which showed complete lysis in 50% of the cases along with shrinkage of nuclei of epithelial cells with subsequent loss of chromatin details. The comparison of three techniques were done. For lysis of RBCs in smear background NSRT was found to be the most effective with which almost complete lysis was observed in 91.33% cases. Our results are in accordance with other studies who reported complete lysis in 93% cases with NSRT.9 With Carnoy’s fluid and GAA, RBC lysis was complete in 82% and 53.33% cases respectively in the present study. In rest of the smears, lysis was incomplete and background was dirty. Malvi and Anthony9 observed only partial lysis and dirty background in 50% of their cases with Carnoy’s fluid and GAA. For epithelial/mesothelial cell retention, the best results were obtained with NSRT in which cellular retention was seen in 86.65% cases, while with GAA maximum loss of epithelial/mesothelial cells were observed.

4. Mortensen P, Jacobsen B. Biochemical examination of ascitic fluid in relation to a malignant or benign etiology. Laeger 1990;152:514-6. 5. Richardson M, Garrison RN, Kaelin L. Malignant ascites: clinical and experimental observations. Ann Surg 1995;203:644-51. 6. Nalyor B. Pleural, peritoneal and pericardial fluids. In: Comprehensive Cytopathology. 2nd edition, Bibbo M (Ed.), WB Saunders Company, Philadelphia 1997:551‑620. 7. Gerbes AL, Jungst D, Xie Y, Permanelter W, Paumgartner G. Ascitic fluid analysis for the differentiation of malignancy related and non-malignant ascites: proposal of a diagnostic sequence. Cancer 1991;68: 1808-14. 8. Husain AN, Kumar V. The lung. In: Robins and Cotran Pathologic Basis of Disease. 7th edition, Kumar V, Abas AK, Fausto N, (Eds.), Saunders Company, Philadelphia 2004:711-72. 9. Malvi SG, Anthony IP. A comparison of methods to improve quality of smears in bloody cell samples of serous fluids. J Cytol 2000;17:15-22. 10. Ng WF, Choi FB, Cheung LH. Rehydration in air-dried smears with normal saline - application in fluid cytology. Acta Cytol 1994;38:56-64.

Cytological preservation was best with Carnoy’s technique among all the three methods.

11. Gupta S, Sodhani P, Chachra KL. Rehydration of air dried cervical smears: a feasible alternative to conventional wet fixation. Obstet Gynaecol 2003;102:761-4.

Conclusion

12. Dahlstrom JE, Holdswarth J, Basett ML, Jain S. Rehydration of air dried smears. An alternative method for cytologic analysis of exfoliative cells. Acta Cytol 1999;43:214-7.

The most effective method for RBC lysis in smear background and cell retention is NSRT followed by Carnoy’s fixative. Nuclear and cytoplasmic characters are best preserved with Carnoy’s technique followed by GAA. References 1. Frist B, Kahan AV, Koss LG. Comparison of diagnostic value of biopsies of the pleura and cytologic evaluation of pleural fluid. Am J Clin Pathol 1979;72:48-51. 2. Sherwani R, Akhtar K, Naqvi AH, Akhtar S, Abrari A, Bhargava R. Diagnostic and prognostic significance of cytology in effusions. J Cytol 2005;22:73-7. 3. Naib ZM. Effusions. In: Cytopathology, 4th edition, Little Brown, London 1996:279-310.

13. Chan JK, Kung IT. Rehydration of air-dried smears with normal saline application in fine-needle aspiration cytology examination. Am J Clin Pathol 1988;89:30-4. 14. Agoff SN, Dean T, Nixon BK, Ingalls-Severn K, Rinker L, Grieco VS. The efficacy of reprocessing unsatisfactory cervicovaginal ThinPrep specimen with and without glacial acetic acid: effect on Hybrid Capture II human papillomavirus testing and clinical follow-up. Am J Clin Pathol 2002;118:727-32. 15. Rowe RL, Bentz JS. A simple method to determine the need for glacial acetic acid treatment of bloody ThinPrep pap tests before slide processing. Diag Cytopathol 2004; 31:321-5.

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

case report clinical practice

Melioidosis with Brain Stem Abscess: A Case Report and Review of Literature Samit Mehta*, B Chendilnathan*, Ram Gopalakrishnan**, MA Thirunarayan†, G Vijaya Kumar‡

Abstract Melioidosis of the brain stem is rare and often not diagnosed. It is being increasingly reported in India. A case of brain stem melioidosis is reported. Clinical, pathological, microbiological features and their treatment is discussed. Key words: Melioidosis, brain stem abscess

elioidosis of the brain stem is rare. Early diagnosis and treatment is difficult. A case of melioidosis of the brain stem associated with parotid infection is reported herein. Case Report

improvement. Pus from the left parotid wound grew a nonfermenting gram-negative bacillus identified as Burkholderia pseudomallei. Stereotactic aspiration of the pontomedullary abscess revealed the same organism. A diagnosis of melioidosis was made. Induction phase treatment with ceftazidime was started and continued

A 34-year-old diabetic housewife presented with subacute onset of painful swelling in the left parotid region of four months duration. Incision and drainage of the parotid swelling was done. Persistent watery discharge was followed by impaired healing of the wound. Subsequently, facial deviation occurred with difficulty in swallowing, difficulty in speech and a productive cough. Retrospectively, it was confirmed that the patient had not traveled outside India. Examination revealed an incised wound over the left parotid, discharging watery fluid (Fig. 1). There was left fifth to tenth cranial palsies with left cerebellar signs. Magnetic resonance imaging (MRI) of the brain revealed conglomerate ring enhancing lesions in the pontomedullary region (Figs. 2 and 3). Mantoux test showed no induration and HIV ELISA was negative. Chest X-ray was unremarkable.

Figure 1. Discharging sinus in left the parotid region.

Antituberculous treatment had been started empirically elsewhere 20 days earlier without clinical *Dept. of Neurosurgery **Dept. of Infectious Disease † Dept. of Microbiology ‡ Dept. of Diabetology Apollo Speciality Hospitals, Chennai Address for correspondence Dr Samit Mehta Dept. of Neurosurgery, Apollo Speciality Hospitals, Chennai - 600 035 E-mail: drsamitathem@yahoo.co.in

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

(A)

(B)

Figure 2. MRI Brain: (A) T1 image showing a hypointense lesion in left side of pons. (B) Postgadolinium showing a ring enhancing lesion.

case report

Figure 3. MRI brain with gadolinium showing multiple ring enhancing lesions in pontomedullary region.

for 14 days. Neurological symptoms improved and parotid wound healed completely. Maintenance therapy with cotrimoxazole and doxycycline was then commenced. Follow-up two months later revealed that the multiple cranial nerve palsies had improved significantly. Discussion Melioidosis caused by B. pseudomallei constitutes a broad-spectrum of acute, subacute and chronic, local and systemic, clinical and subclinical disease processes.1 Melioidosis is mainly found in the tropics and is endemic in South East Asia with most of the cases reported from Thailand and Northern Australia.2,3,9 The disease is being increasingly reported from India.4,5 The organism is a free living, small, motile, aerobic gram-negative bacillus normally found in soil, ponds and rice paddies from endemic areas.1,3 Humans contract the disease through soil contamination following abrasion, ingestion or inhalation. Route of spread is hematogenous.6 The organism does not establish colonization without causing infection and is rarely transmitted from person-to-person.6 Melioidosis can present in different forms.6 Neurological melioidosis is rare and there are only a few case reports.2,8 Neurological symptoms manifest as brain stem encephalitis, cerebral abscess, cranial nerve palsies (most commonly the facial nerve).6 Melioidosis should be considered in the differential diagnosis of ring enhancing abscess-like lesions in the brain, particularly when they do not respond to standard treatment. Acute pulmonary infections vary 24

in severity from mild bronchitis to extensive necrotizing pneumonia. Chest roentgenograms typically reveal upper lobe infiltrates that may mimic tuberculosis.6 Acute localized suppurative skin infections associated with nodular lymphangitis and regional lymphadenitis result from direct inoculation at sites of minor skin trauma.6 Suppurative parotitis has been reported from Thailand and occasionally from other countries.6 Recrudescent disease arises from inactive sites of infection and is perhaps triggered by intercurrent illness.3,4 The progression is more likely in chronically debilitated patient.3 The acute septicemic form of melioidosis usually follows a rapid downhill course, ending in early death.4,7 Mortality remains high.8 Melioidosis is usually suspected when a febrile patient from an endemic area presents with acute lower respiratory tract illness associated with tachypnea, exhibits unusual skin or subcutaneous lesions, or has a chest roentgenogram suggesting tuberculosis in the absence of sputum-associated tubercle bacilli.4,9,10 An etiologic diagnosis may be made by a culture positive for B. pseudomallei.5 The mainstay of treatment for melioidosis is administration of appropriate antibiotic combined with appropriate surgical drainage of the abscess and aggressive support for patients with septicemic form of the disease.6 The drug of choice is ceftazidime or imipenem until the patient shows clinical improvement (often after 10-30 days) at which time the therapy can be switched to an oral maintenance regimen comprising of a combination of chloramphenicol, cotrimoxazole, and doxycycline and continued for 12-20 weeks.3,6 Conclusion Melioidosis should be thought of in cerebral abscesses that are associated with abscesses elsewhere or are not improving with standard therapy. Culture of pus from an abscess will yield the diagnosis. It is essential that the microbiologist is aware of possibility of B.Â pseudomallei being a rare cause for such an infection. Medical therapy is effective. With improvements in health care and diagnostic microbiology and increased travel it will probably be increasingly recognized in the years to come. Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

case report Acknowledgement We are thankful to Dr. G Vijaya Kumar for reviewing the manuscript.

Suggested Reading 1. Christopher AO, Matthew P. In: Harrison Principles of Internal Medicine. 15th edition, McGraw Hill, New York 2001. 2. Pits S, Chea FK, Jamal F. Melioidosis with brain abscess: Postgrad Med J 1988;64:140-2. 3. White NJ. Melioidosis. Lancet 2003;361:1715-22. 4. Badsha H, Edwards CJ, Chng HH. Melioidosis in systemic lupus erythematosus: the importance of early diagnosis and treatment in patients from endemic areas. Lupus 2001;10:821-3. 5. Mathew S, Perakath B, Mathew G, Sitaram V, Nair A, Lalitha MK, et al. Surgical presentation of melioidosis in India. Natl Med J India 1999;12:59-61. 6. Mandell GL, Douglas JE, Bennett. In: Principles and Practice of Infectious Diseases. Elsevier Churchill Livingstone 2005.

7. Kasantikul V, Lerdlum S, Suwanwela N. Cerebral abscesses due to Pseudomonas pseudomallei. J Med Assoc Thai 1992;75:536-41. 8. Lath R, Rajshekhar V, George V. Brain abscess as the presenting feature of melioidosis. Br J Neurosurg 1998;12:170-2. 9. Padiglione A, Ferris N, Fuller A, Spelman D. Brain abscesses caused by Burkholderia pseudomallei. J Infect 1998;36:335-7. 10. Thurnheer U, Novak A, Michel M, Ruchti C, Jutzi H, Weiss M. Septic melioidosis following a visit to India. Schweiz Med Wochenschr 1988;118:558-64. 11. Chadwick DR, Ang B, Sitoh YY, Lee CC. Cerebral melioidosis in Singapore: a review of five cases. Trans R Soc Trop Med Hyg 2002;96:72-6. 12. Kanungo R, Padhan P, Bhattacharya S, Srimannarayana J, Jayanthi S, Swaminathan RP. Melioidosis - a report from Pondicherry, South India. J Assoc Physicians India 2002;50:1438-9. 13. Rao PS, Dhawan R, Shivananda PG. Burkholderia pseudomallei infections. Trop Doct 2002;32:174-5.

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

Practice Guidelines clinical practice

International Consensus Group Issues Recommendations for Management of Upper GI Bleeding

he clinical and economic burden of upper gastrointestinal (GI) bleeding is considerable, with the annual incidence ranging from 48 to 160 cases per 100,000 adults and mortality rates ranging from 10 to 14 percent. In response to new data that may lead to improved patient outcomes, the International Consensus Upper Gastrointestinal Bleeding Conference Group-a multidisciplinary group of 34 experts from 15 countries-developed international guidelines for managing nonvariceal upper GI bleeding. The guidelines include new recommendations, as well as updates to the 2002 guidelines from the British Society of Gastroenterology and the 2003 consensus guidelines from the Nonvariceal Upper GI Bleeding Consensus Conference Group.

levels; melena; transfusion requirement; fresh red blood on rectal examination, in the emesis, or in the nasogastric aspirate; sepsis; and elevated urea, creatinine, or serum transaminase levels.

The evidence rating system implemented is defined as follows: 1A = strong recommendation, highquality evidence; 1B = strong recommendation, moderate-quality evidence; 1C = strong recommendation, low- or very low-quality evidence; 2A = weak recommendation, high-quality evidence; 2B = weak recommendation, moderate-quality evidence; 2C = weak recommendation, low- or very lowquality evidence. Grade 1 recommendations should be interpreted as “do it” or “do not do it”; grade 2 recommendations should be interpreted as “probably do it” or “probably do not do it.”

New recommendation: In patients receiving anticoagulants, correction of coagulopathy is recommended, but should not delay endoscopy. (Grade: 2C) Available data suggest that it may not be necessary to delay endoscopy in patients with mild to moderate coagulopathy. One study of patients undergoing endoscopy found no difference in rebleeding, surgery, mortality, or complication rates between patients receiving warfarin and those not receiving anticoagulants.

Resuscitation, Risk Assessment, and Pre-endoscopy Management Revised recommendation: Prognostic scales are recommended for early stratification of patients into lowand high-risk categories for rebleeding and mortality. (Grade: 1C) Early identification of high-risk patients can facilitate appropriate intervention, which minimizes morbidity and mortality. Stratification should be based on clinical, laboratory, and endoscopic criteria. Predictors of increased risk of rebleeding include age older than 65 years; shock; poor overall health; comorbid illnesses; low initial hemoglobin (Hgb) Source: Adapted from Am Fam Physician. 2010;81(12):1495-1497.

New recommendation: Blood transfusions should be administered in patients with an Hgb level of 7 g per dL (70 g per L) or less. (Grade: 1C) Patients should be considered for transfusion based on their underlying condition, hemodynamic status, and markers of tissue hypoxia in acute situations. Red blood cell transfusion is rarely needed in patients with an Hgb level greater than 10 g per dL (100 g per L) and is usually needed when the Hgb level is less than 6 g per dL (60 g per L).

New recommendation: Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield. (Grade: 2B) Although promotility agents may be useful in selected patients with suspected blood in the stomach, they are not recommended for routine use in patients with upper GI bleeding. Revised recommendation: Selected patients with acute ulcer bleeding who are at low risk of rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy. (Grade: 1A) One randomized controlled trial (RCT) assessing the role of early discharge in low-risk patients found no difference in rates of recurrent bleeding. None of the patients who were discharged early experienced serious adverse events, underwent surgery, or died during the 30-day follow-up. Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

Practice Guidelines Revised recommendation: Pre-endoscopic proton pump inhibitor (PPI) therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention, but should not delay endoscopy. (Grade:â&#x20AC;&#x2018;1B) PPI therapy may be useful, especially in patients suspected to have high-risk stigmata. However, it has not been shown to affect rebleeding, surgery, or mortality. Endoscopic Management Revised recommendation: Early endoscopy (within 24 hours of presentation) is recommended for most patients with acute upper GI bleeding. (Grade: 1B) Early endoscopy has been shown to be safe and effective in all risk groups, although it may need to be delayed or deferred in certain high-risk patients, such as those with active acute coronary syndrome or suspected perforation. Revised recommendation: The finding of a clot in an ulcer bed warrants targeted irrigation to attempt dislodgement, with appropriate treatment of the underlying lesion. (Grade: 2B) Revised recommendation: The role of endoscopic therapy for ulcers with adherent clots is controversial. Intensive PPI therapy alone may be sufficient. (Grade: 2B) Endoscopic therapy for adherent clots involves preinjecting with epinephrine before shaving, followed by applying combination treatment to the remaining stigmata of hemorrhage. A meta-analysis of five RCTs involving patients with adherent clots found no significant benefits for endoscopic therapy compared with no endoscopic therapy. Revised recommendation: Epinephrine injection alone provides suboptimal effectiveness and should be used in combination with another method. (Grade: 1B) Revised recommendation: Clips, thermocoagulation, or sclerosant injection should be used in patients with highrisk lesions, alone or in combination with epinephrine injection. (Grade: 1A) Meta-analyses showed that adding a second procedure (e.g., an injection of alcohol, thrombin, or fibrin glue; thermal contact; clips) to epinephrine injection is superior to epinephrine injection alone Adding a second procedure for high-risk stigmata significantly reduced rebleeding, surgery, and mortality compared with epinephrine monotherapy. Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

Revised recommendation: Routine second-look endoscopy is not recommended. (Grade: 2B) The most recent data do not show a benefit with second-look endoscopy (i.e., a preplanned systematic endoscopy performed 16 to 24 hours after initial endoscopy). When available, high-dose intravenous PPI therapy is the current standard. Patients with high-risk presentations may benefit from second-look endoscopy, but more research is needed. Pharmacologic Management Revised recommendation: An intravenous bolus followed by continuous-infusion PPI therapy should be used to decrease rebleeding and mortality in patients with highrisk stigmata who have undergone successful endoscopic therapy. (Grade: 1A) Strong evidence supports the use of high-dose intravenous PPI therapy following successful endoscopy. No conclusions may be made at this time regarding low-dose intravenous PPI therapy or high-dose oral PPI therapy. New recommendation: Patients should be discharged with a prescription for a single daily dose oral PPI; the duration should be dictated by the underlying etiology. (Grade: 1C) Once-daily PPI therapy has been shown to be effective in patients with peptic ulcer disease. However, some studies demonstrate relatively low healing rates for complicated or severe esophagitis, and twice-daily doses may be needed. Nonendoscopic and Nonpharmacologic In-Hospital Management New recommendation: Most patients who have undergone endoscopic hemostasis for high-risk stigmata should remain hospitalized for at least 72 hours. (Grade: 1C) Studies show that after endoscopic therapy, it takes 72 hours for most high-risk lesions to become low-risk lesions. More research is needed to determine whether selected high-risk patients may be treated in the outpatient setting. New recommendation: Where available, percutaneous embolization can be considered as an alternative to surgery in patients for whom endoscopic therapy has been unsuccessful. (Grade: 2C) Percutaneous or transcatheter arterial embolization may be considered as an alternative to surgery, especially in patients who are high-risk candidates for surgery. Although uncommon, possible complications include bowel ischemia; secondary duodenal stenosis; and gastric, hepatic, and splenic infarction. 27

Practice Guidelines Revised recommendation: Patients with bleeding peptic ulcers should be tested for Helicobacter pylori and receive eradication therapy if it is present, with confirmation of eradication. (Grade: 1A) New recommendation: Negative H. pylori diagnostic tests obtained in the acute setting should be repeated. (Grade:â&#x20AC;&#x2018;1B) Diagnostic tests for H. pylori (e.g., serology, histology, urea breath test, rapid urease test, stool antigen, culture) may show increased false-negative rates in patients with acute bleeding; therefore, repeat testing after an initial negative result is needed. Postdischarge, Aspirin, and NSAIDs New recommendation: In patients with previous ulcer bleeding who require a nonsteroidal anti-inflammatory drug (NSAID), treatment with a traditional NSAID plus PPI or a cyclooxygenase-2 (COX-2) inhibitor alone is associated with a clinically important risk of recurrent bleeding. (Grade: 1B) New recommendation: In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk of recurrent bleeding compared with COX-2 inhibitors alone. (Grade: 1B) Adding a PPI to traditional NSAID therapy is recommended to reduce the risk of upper GI

complications, although the combination of a COX-2 inhibitor plus a PPI was associated with the greatest reduction in risk. Other studies found a decreased risk of endoscopic ulcers with a COX-2 inhibitor plus a PPI, compared with a COX-2 inhibitor alone. New recommendation: In patients who take low-dose aspirin and develop acute ulcer bleeding, aspirin therapy should be restarted as soon as the risk of cardiovascular complication is thought to outweigh the risk of bleeding. (Grade: 1B) Discontinuing aspirin therapy for an extended period increases thrombotic risk in patients who require cardio-protective aspirin therapy. One meta-analysis showed that nonadherence or withdrawal of aspirin therapy is associated with a threefold risk of major adverse cardiac events. According to the American Heart Association, the decision to discontinue aspirin therapy in patients with acute ulcer bleeding should be made on an individual basis. New recommendation: In patients with previous ulcer bleeding who require cardiovascular prophylaxis, clopidogrel alone has a higher risk of rebleeding than aspirin combined with a PPI. (Grade: 1B) Two RCTs showed a significant reduction in rebleeding in patients taking aspirin plus a PPI compared with those receiving clopidogrel alone, although there was no significant effect on mortality. n

...Contâ&#x20AC;&#x2122;d from page 18 address and prevent errors from occurring. The fourth column lists technology that may help prevent these errors. Technology can be a powerful tool in the fight against medication errors but only when it is used appropriately within a well-designed medication use system. The key summarizes the technology addressed in the tables, along with specific criteria that ISMP feels should be included.

Suggested Readings 1. Cohen MR, ed. Medication Errors. 2nd ed. Washington, DC: American Pharmacists Association; 2007. 2. Institute for Safe Medication Practices Website: www. ismp.org. 3. Institute for Safe Medication Practices. (2009). ISMP Medication Safety Alert! Acute Care Edition newsletter www.ismp.org/newsletters/default.asp. Accessed March 18, 2010.

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

photo quiz clinical practice

Acutely Swollen Tongue in a Middle-aged Woman

55-year-old black woman presented to the emergency department with acute swelling of the tongue and mild respiratory distress. Her tongue began swelling about three hours earlier, and mild respiratory distress developed during the hour before presentation. She had a history of hypertension, diabetes mellitus, seizure disorder, and moderate mental retardation. She was taking aspirin, lisinopril, metformin, phenobarbital and doxazosin and there was no change in medications in the previous three years. She had no known medication or environmental allergies. Examination of the oral cavity revealed copious secretions and macroglossia (see accompanying figure). Respiratory examination showed rare crackles, but no wheezing. Question Based on the patientâ&#x20AC;&#x2122;s history and physical examination, which one of the following is the most likely diagnosis? A. Acromegaly. B. Amyloidosis. C. Hypothyroidism. D. Medication-induced angioedema. E. Superior vena cava syndrome. Discussion The answer is D: medication-induced angioedema, likely from the angiotensin-converting enzyme (ACE) inhibitor lisinopril. ACE inhibitor-associated angioedema is a self-limited, localized swelling that commonly affects the lips, tongue, and face. Pruritus and urticaria are usually absent. The incidence of ACE inhibitor-associated angioedema varies from 0.1 to 6 percent.1 Most cases occur within the first month of starting treatment, with the highest incidence in the first week. However, symptom onset Source: Adapted from Am Fam Physician. 2010;82(3):279-280.

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

Figure.

has been reported anywhere from one day to 10 years after starting treatment. Angioedema is more common in black persons, women, smokers, and persons with a history of seasonal allergies. Diabetes seems to decrease the risk.1 The condition is thought to be related to elevations in bradykinin and substance P levels, which cause inflammation and fluid leakage in the postcapillary venules. This leads to a well-demarcated, localized, and nonpitting subdermal edema.1 Although there have been reports of angioedema related to angiotensin receptor blockers (ARBs), the rates are similar to those in the general population. ARBs are generally considered safe in patients with a history of angioedema from ACE inhibitors.2 Angioedema should resolve after the discontinuation of the causative ACE inhibitor, and further treatment with other ACE inhibitors is contraindicated. Depending on the severity of symptoms, supportive care may be required, including treatment with epinephrine and intubation in anticipation of laryngeal obstruction.1,3 Acromegaly is caused by excess growth hormone and manifests as soft tissue and bony overgrowth. Other features include enlarged face, hands, feet, and tongue; coarsening of facial features; and development of diabetes and macroglossia. Duration of symptoms, from onset to diagnosis, is typically 12 years.4 29

photo quiz Summary Table Condition

Characteristics

Acromegaly

Soft tissue and bony overgrowth from excess growth hormone; insidious onset of enlarged features, including face, hands, feet, and tongue

Amyloidosis

Amyloid may infiltrate muscles and cause pseudohypertrophy of the tongue; kidneys, heart, and liver are the most common sites of deposition; usually not acute in onset

Hypothyroidism

May cause fatigue, constipation, and cold intolerance; pale skin, sparse hair, periorbital puffiness, and macroglossia may progress to a stuporous state and generalized edema; usually chronic

Medicationinduced angioedema

May occur days or years after initiation of angiotensin-converting enzyme inhibitor; usually sudden-onset edema of lips, tongue, and face

Superior vena cava syndrome

Manifestation of dilation of the veins in the upper thorax and neck, accompanied by plethora, facial edema, headache, and reduced consciousness; gradual and progressive swelling over days to weeks

Amyloidosis is characterized by deposition of the amyloid protein in various parts of the body. Although the kidneys, heart, and liver are the most common sites of deposition, amyloid may infiltrate the muscles and cause pseudohypertrophy of the tongue. Macroglossia may be the first manifestation of amyloidosis.5 Hypothyroidism is usually chronic and causes symptoms such as fatigue, constipation, and cold

intolerance. Pale skin, sparse hair, periorbital puffiness, and macroglossia may sometimes progress to a stuporous state and generalized edema. Diagnosis is made by the presence of decreased serum thyroxine and increased thyroid-stimulating hormone levels.6 Superior vena cava syndrome is a manifestation of dilation of the veins in the upper thorax and neck, accompanied by plethora, facial edema, headache, and reduced consciousness. The condition leads to gradual and progressive swelling over days to weeks and is often caused by a malignancy directly compressing the vena cava.7 References 1. Byrd JB, Adam A, Brown NJ. Angiotensin-converting enzyme inhibitor-associated angioedema. Immunol Allergy Clin North Am. 2006;26(4):725-737. 2. Temiño VM, Peebles RS Jr. The spectrum and treatment of angioedema. Am J Med. 2008;121(4):282-286. 3. Sabroe RA, Black AK. Angiotensin-converting enzyme (ACE) inhibitors and angio-oedema. Br J Dermatol. 1997;136(2):153-158. 4. Colao A, Ferone D, Marzullo P, Lombardi G. Systemic complications of acromegaly: epidemiology, pathogenesis, and management. Endocr Rev. 2004;25(1):102‑52. 5. Xavier SD, Bussoloti IF, Müller H. Macroglossia secondary to systemic amyloidosis: case report and literature review. Ear Nose Throat J. 2005;84(6):358‑361. 6. Wall CR. Myxedema coma: diagnosis and treatment. Am Fam Physician. 2000;62(11):2485-2490. 7. Cheng S. Superior vena cava syndrome: a contemporary review of a historic disease. Cardiol Rev. 2009;17(1):16‑23.

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

news and views clinical practice

Continuous Monitoring of Surgery Patients can Reduce ICU Transfers, Rescue Events

10-month, around-the-clock monitoring study of patients undergoing orthopedic surgery has given researchers keys to more efficient tracking of vital signs in the hospital. The results demonstrate that continuous monitoring avoids the pitfalls of measuring vital signs only every two, four or eight hours, as is typical in most hospitals, the researchers said. The study also points to the importance of differentiating surveillance monitoring—of all patients regardless of risk—and “condition” monitoring of patients requiring the most scrutiny, and of carefully calibrating alarm thresholds to balance sensitivity and specificity, said lead author Andreas Taenzer, MD, assistant professor of anesthesiology and pediatrics at Dartmouth-Hitchcock Medical Center, in Lebanon, N.H. “I think it’s a very nice, early study into how we can do this with high fidelity,” said Brad Winters, MD, PhD, assistant professor of anesthesiology and critical care, and director of the Johns Hopkins Hospital Adult Rapid Response System Program, in Baltimore. “There’s a lot of data in the literature saying that intermittent recording of vital signs is unreliable and catches problems much too late. We need to be able to record abnormalities in a form that’s portable so ambulatory patients can be monitored, acceptable to patients, and reliable in its ability to notify nurses or doctors without too many false-positives or false-negatives.” The data come from a before-and-after study at Dartmouth, which in December 2007 installed the Patient SafetyNet (Masimo) monitoring system, one of several continuous-monitoring technologies on the market. They chose this system “because of its configurability and ability to perform direct nurse notification,” Dr Taenzer noted. (Masimo has supported the Hitchcock Foundation, which helped fund the research.) Dr Taenzer’s group followed patients in the 36-bed orthopedic surgery unit, which had an average of 200 patient-days and 53 patient discharges per week. Source: Adapted from McMahon Publishing; Anesthesiology News, April 2010.

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

Prior to implementing the monitoring system, the unit averaged 3.4 rescue events per 1,000 patients discharged. It averaged 1.2 per 1,000 with the technology (P = 0.01) – a decline from 37 to 11 patients per year, the researchers said. (A rescue event was defined as activation of the hospital’s rapid response team, a STAT airway or a major code call.) Similarly, the number of transfers to the ICU fell from 5.6 to 2.9 per 1,000 patient-days (P = 0.02), or from 54 to 28 transfers per year. That amounts to a reduction in total ICU days of 135 for the unit, the researchers said. Although continuous monitoring may have clear utility, the steady stream of data creates demands, particularly on the nursing staff, the researchers said. False alarms are a particular drain on resources. Because the Dartmouth orthopedic unit had a nurse-to-patient ratio of 1-to-5–compared with 1-to-1 for an ICU–at the time of the study, false alarms were more than a mere bother, the researchers said. “An alarm redirects nurse attention from other important tasks, and a high frequency of alarms will desensitize staff, leading to delayed responses,” they wrote. “Therefore, it is necessary to trade off earlier notification of some deterioration against limiting the nuisance alarms generated by self-correcting changes or false readings.” To avoid this problem, the Dartmouth team lowered the alarm triggers on the monitoring system to a spot oxygen saturation (SpO2) below 80% and a heart rate of either fewer than 50 or more than 140 beats per minute. They also adjusted the device to include a 15-second delay from the detection of SpO2 or heart rate outside these limits to an audio alarm sounding at the bedside, and there was another 15-second delay before a paged announcement to the nurses on duty. Some patients have physiologic abnormalities that might require adjustments to the alarm thresholds. As a result, the Dartmouth team allowed nurses and physicians to change the alert values based on a particular patient’s situation. 31

news and views Given the results of the study, the less sensitive settings did not appear to jeopardize patient safety. However, the researchers did not compare outcomes with those associated with stricter triggers. The Dartmouth group now is studying whether higher alarm thresholds would indeed manage to pick up more patients who might require intensive care, he added. Finding a Baseline In a finding that could help establish a baseline for other studies of vital signs, the Dartmouth investigators analyzed initial data generated by continuous monitoring. They found that patients on the orthopedic surgery unit spent 12.4% of their time on the ward with an SpO2 below 93% and more than 30% of their time with a heart rate greater than 90 beats per minute. “This has never been done or reported before,” Dr Taenzer said. “It is really fundamental groundwork.”

The baseline figures provide a means of exporting continuous monitoring to other units and patient populations, Dr Taenzer noted. Knowing the baseline distribution for a given population may help to optimize alarm settings for that population, he said. In an editorial accompanying the publication of these results in Anesthesiology, John Abenstein, MD, and Bradly Narr, MD, of Mayo Clinic in Rochester, Minn., were enthusiastic about the research (2010;112: 274-275). “The decision of the investigators to only trigger an alarm when there was little ambiguity that an intervention was necessary assured response on the part of the clinical staff,” the pair wrote. “We believe that Taenzer et al. have shown us a glimpse of the future. Not only will such systems allow us to improve the quality of care for our patients, but [they] will also be a key to lowering costs.” n

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

Journal Scan ...

Enoxaparin: A Pharmacologic and Clinical Review Introduction: Both arterial and venous thromboembolism constitute a significant disease burden worldwide, leading to major use of healthcare resources. As anticoagulants play a pivotal role in the treatment of these disorders, it is vital for healthcare providers to have sufficient knowledge of their biochemical and clinical attributes. Areas covered: Enoxaparin is one of the most commonly used low-molecular-weight heparins in a wide variety of thromboembolic disorders and has several advantages over unfractionated heparin. An analysis of its biophysical profile, with special emphasis on pharmacokinetic and pharmacodynamic properties, is undertaken in this article. In addition, most recent major clinical studies elucidating its role in common thromboembolic conditions are discussed, while keeping the historical perspective at hand. Readers will be able to understand the pharmacologic properties of enoxaparin with their clinical relevance for day-to-day use and critically analyze the amount and weight of scientific evidence behind its use in various disorders. Expert opinion: In summary, enoxaparin has been shown, by a vast amount of scientific data, to be a safe and effective agent in the treatment of a whole spectrum of acute coronary syndromes, with similar efficacy and safety in the prevention and treatment of venous thromboembolism. Iqbal Z, Cohen M. Expert Opin Pharmacother 2011;12(7):1157-70.

Differentiation of Parenteral Anticoagulants in the Prevention and Treatment of Venous Thromboembolism Background: The prevention of venous thromboembolism has been identified as a leading priority in hospital safety. Recommended parenteral anticoagulant agents with different indications for the prevention and treatment of venous thromboembolism include unfractionated heparin, low-molecular-weight heparins Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

research review clinical practice

and fondaparinux. Prescribing decisions in venous thromboembolism management may seem complex due to the large range of clinical indications and patient types, and the range of anticoagulants available. Methods: MEDLINE and EMBASE databases were searched to identify relevant original articles. Results: Low-molecular-weight heparins have nearly replaced unfractionated heparin as the gold standard antithrombotic agent. Low-molecular-weight heparins currently available in the US are enoxaparin, dalteparin, and tinzaparin. Each low-molecular-weight heparin is a distinct pharmacological entity with different licensed indications and available clinical evidence. Enoxaparin is the only low-molecular-weight heparin that is licensed for both venous thromboembolism prophylaxis and treatment. Enoxaparin also has the largest body of clinical evidence supporting its use across the spectrum of venous thromboembolism management and has been used as the reference standard comparator anticoagulant in trials of new anticoagulants. As well as novel oral anticoagulant agents, biosimilar and/or generic low-molecular-weight heparins are now commercially available. Despite similar anticoagulant properties, studies report differences between the branded and biosimilar and/or generic agents and further clinical studies are required to support the use of biosimilar low-molecular-weight heparins. The newer parenteral anticoagulant, fondaparinux, is now also licensed for venous thromboembolism prophylaxis in surgical patients and the treatment of acute deep-vein thrombosis; clinical experience with this anticoagulant is expanding. Conclusions: Parenteral anticoagulants should be prescribed in accordance with recommended dose regimens for each clinical indication, based on the available clinical evidence for each agent to assure optimal safety and efficacy. Fareed J, Adiguzel C, Thethi I. Thromb J 2011;28;9(1):5.

research review Efficacy and Safety of Enoxaparin During Hemodialysis: Results from the HENOX Study Background: Low molecular weight heparins (LMWHs) have been suggested as an anticoagulant in hemodialysis (HD) since they provide convenient usage, safety and effective outcomes. Objective: Determine clinical efficacy and safety of enoxaparin sodium for the anticoagulation effect during HD in 99 clinically stable end-stage renal disease (ESRD) patients. Material and method: This prospective open-label study was conducted in seven hemodialysis centers in Thailand HD prescription during the present study was similar to the previous prescriptions including the type of dialyzer. Enoxaparin sodium 0.7 mg/kg was administered into a pre-dialyzer arterial line at the beginning of the HD session. The anticoagulation effect was monitored by visual inspection of the HD line hourly and inspection of the dialyzer at the end of HD session. Vascular access compression time was monitored at both arterial and venous sites separately at the end of the HD. Results: HD with enoxaparin sodium resulted in no fibrin/clot formation in a hemodialysis line in 97 cases (98%), and no significant clot formation in a dialyzer in 96 cases (97%). The mean vascular compression time was 5.63 ± 1.90 minutes at the arterial site and 5.72 ± 2.61 minutes at the venous site. Neither major adverse events nor major hemorrhages were reported Prolonged activated partial thromboplastin times (aPTT) at 30 minutes after hemodialysis were reported in two cases. These abnormal aPTT cases returned to normal levels within 24 hours and 72 hours, respectively.

Radical Reduction of Cephalosporin use at a Tertiary Hospital after Educational Antibiotic Intervention during an Outbreak of Extended-spectrum [beta]-lactamase-producing Klebsiella Pneumoniae Objectives: During an outbreak of extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae at our hospital, we performed an educational antibiotic intervention aimed at reducing prescriptions of secondand third-generation cephalosporins and preventing increased use of fluoroquinolones and carbapenems. In this report, we describe the implementation strategy used and evaluate the intervention effect according to Cochrane recommendations. Methods: New recommendations for empirical intravenous antibiotic treatment were communicated to prescribers throughout the hospital by infectious diseases physicians working with Strama (the Swedish strategic program against antibiotic resistance). No restrictive measures were used. The intervention effect was analyzed with interrupted time series (ITS) regression analysis of local and national monthly antibiotic sales data. Results: A radical immediate and sustained reduction was demonstrated for the cephalosporins targeted in the intervention, whereas consumption of piperacillin/ tazobactam and penicillin G increased substantially. Fluoroquinolone and carbapenem use was essentially unchanged. The ESBL outbreak subsided and no increased resistance to piperacillin/tazobactam was detected in K. pneumoniae, Escherichia coli or Pseudomonas aeruginosa blood isolates during the 2.5 year follow-up.

Conclusion: The present study suggests that a singledose regimen of enoxaparin sodium 0.7 mg/kg is an effective, well-tolerated, and convenient alternative to sodium heparin.

Conclusions: Our study clearly demonstrates that an educational intervention can have an immediate and profound effect on antibiotic prescription patterns at a large tertiary hospital. ITS regression analysis of local and national antibiotic sales data was valuable to readily assess the immediate and sustained effects of the intervention.

Vareesangthip K, Thitiarchakul S, Kanjanakul I, et al. J Med Assoc Thai 2011;94(1):21-6.

Tängdén T, Eriksson BM, Melhus A, et al. J Antimicrob Chemother 2011;66(5):1161-7.

Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011

emedinews section clinical practice

From eMedinewS

Higher Death Rates Seen in Kidney Failure Patients Through Central Line Catheter As per the American Society of Nephrology wrote, patients on peritoneal dialysis (PD) typically have a higher early survival rate than patients on hemodialysis (HD). New data suggest that this difference may be explained by a higher risk of early deaths among patients undergoing HD with central venous catheters, according to a study appearing in an upcoming issue of the Journal of the American Society of Nephrology. Access Type may Impact Hemodialysis Patient Survival Central venous catheters may account for the poorer survival among HD patients, according to an analysis, which included 40,526 adults, in the Journal of the American Society of Nephrology. Use of a central port for dialysis was associated with 80% elevated one-year mortality risk compared with PD, the researchers found. ICU Cleaning Model may Reduce MRSA Infection Rates An enhanced cleaning protocol appeared to cut the risk that a patient in the intensive care unit would get methicillin-resistant Staphylococcus aureus (MRSA) from the room’s previous occupant, according to a in study the Archives of Internal Medicine. Medicolegal Update Sudden Cardiac Arrest

Some people confuse sudden cardiac arrest (SCA) with a heart attack. They are by no means the same.  19 cases of SCA has been examined and certified by me in AIIMS in the year 2010 where defibrillator was not used prior to fatality.



A heart attack, caused by blockage of the arteries, the victim feels severe chest pains but almost always remains conscious. SCA victims will always lose consciousness. SCA is the result of a ‘ventricular fibrillation’ a quivering of the heart which prevents the heart muscle from pumping blood to the body. To overcome this condition, the victim will need various forms of help in order to survive. The most important of which may well be the assistance of a defibrillator. Each minute that passes without defibrillation decreases the victim’s survival chances by 10-20%. When a defibrillator is used, it in effect kicks the heart muscle into action again, causing it to resume sending blood throughout the body. A defibrillator is a machine used to shock the victim’s heart and restore the heart’s normal rhythmic patterns –Dr Sudhir Gupta, Additional Professor, Forensic Medicine and Toxicology, AIIMS

An Inspirational Story Set Deadlines

A dream is a goal with a deadline. Without a deadline you won’t achieve most of your goals. Why? Because there are so many things in life that will take over your time, and before you know it, a year will have gone by and you will be no closer to your goal than you were before. Set an overall deadline for the completed goal, and also set interim deadlines for each piece that needs to be accomplished. A deadline must be a specific date, not just sometime before the end of the year, or when you get around to it. If you miss a deadline, don’t beat yourself up over it, just set a new one and get back to working on the steps to your goal. n

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Asian Journal of Critical Care Vol. 7, No. 1, January-March 2011