We have studied the effects of bolus doses of midazolam 0.15 mg kg' 1 i.v. on intracranialpressure (ICP), mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) in 12 patients with severe head injury (Glasgow Coma Scale score ^ 6). The study was performed in patients aged 17-44 yr who were sedated (phenoperidine 20 pg kg-1 /r') and paralysed (vecuronium 2 mg h' 1). Midazolam reduced MAP from 89.0 mm Hg to 75.0 mm Hg (P < 0.0001), while CPP decreased from 71.0 mm Hg to 55.8 mm Hg (P < 0.0001). During the study, CPP decreased to less than 50 mm Hg in four patients. Midazolam induced small, non-significant changes in ICP. However, when control ICP was less than 18 mm Hg (n = 7 patients), an increase in ICP was observed. The remaining five patients (control ICP ^18mmHg) exhibited a slight decrease in ICP. These findings suggest that bolus administration of midazolam should be performed with great caution in patients with severe head injury, especially when ICP is less than 18 mm Hg.
ObjectivesThe relationship between high dietary sodium intake and hypertension is well established. Some drugs are associated with high-sodium content, particularly effervescent tablets (ETs). Despite a possible cardiovascular risk associated with the use of such drugs, observational data describing exposure to ETs in ambulatory subjects are lacking.This study aims to estimate the prevalence of exposure to ETs and to highlight factors associated with this exposure in a large French health check-up population.DesignThis was a cross-sectional study.Setting and participantsParticipants were French individuals who underwent medical check-ups at the Investigations Préventives et Cliniques centre between April and June 2017.ResultsIn total, 1043 subjects were included in the study. The prevalence of exposure to ETs in the last 30 days was 26.9% (95% CI 24.2% to 29.6%). Exposure was frequent (ie, two ETs per week or more in the last 30 days) for 7.3% of subjects. Self-medication was the major source of exposure (93.8%). Paracetamol, aspirin, vitamins and betaine accounted for 95.3% of the ETs used. The factors associated with this exposure by multivariate analysis were: male gender, Overseas French origin, depression and body mass index ≥25 kg/m2. A diagnosis of hypertension or treatment with diuretics were not protective factors against exposure to ETs.ConclusionExposure to ETs is frequent in the general population, particularly through self-medication. Clinical conditions associated with low-salt requirements were not associated with lower exposure to ETs, suggesting a lack of awareness by practitioners and patients about this iatrogenic issue.
BKCa channels mediate the relaxation of coronary artery induced by PDE3 and PDE4 inhibition. This is achieved by co-localization of both PDEs with BKCa channels, enabling tight control of cAMP available for channel opening. Contribution of the channel is prominent at rest and on β-adrenergic stimulation. This coupling is lost in heart failure.
AIMS OF THE STUDY:This study assesses clinical interventions by pharmacists prospectively collected from medical and surgical wards, notably the acceptance of interventions, computerised physician order entry (CPOE)related problems, the potential impact of interventions on patient safety evaluated by a multidisciplinary committee, and their evolution over the 10 years since a first assessment.METHODS: A prospective observational study covering 13 months was conducted in a French teaching hospital with a patient information system that integrates an electronic health record (EHR) with a CPOE. Interventions by pharmacists were prospectively recorded using CPOE. All interventions were reviewed by two pharmacists. We assessed the interventions, the possible implications of the CPOE in prescribing errors, and the acceptance of interventions by physicians. A committee reviewed the potential clinical impact for patients. The results were compared with the same outcomes collected 10 years ago in the same hospital. RESULTS: A total of 2141 interventions by pharmacists were reviewed. Among them, 1589 (74.1%) were accepted by physicians. Regarding the potential clinical impact, a total of 1136 (53%) interventions concerned prescriptions that were potentially significant or serious for patients and 42 (2%) of them were potentially life-threatening. Ten years earlier, the acceptance rate was 23%. Moreover, 14.7% of errors were attributed to the use of the software, whereas 10 years earlier the rate of errors was 49%. CONCLUSIONS:The acceptance rate and frequency of CPOE-related errors were better than 10 years before, which is encouraging and shows the importance of regular training and collaboration with healthcare givers to reduce errors. The routine analysis of interventions by pharmacists with medical staff feedback should continue to improve their relevance and effectiveness.
BackgroundExcess dietary sodium is associated with increased blood pressure (BP). Some drugs are associated with high sodium intake (in particular effervescent tablets), but the cardiovascular risk associated with such high sodium-containing drugs (HSCD) is largely underevaluated.ObjectivesTo summarize the evidence for a potential cardiovascular risk associated with exposure to HSCD, and to highlight possible risk factors associated with this iatrogenic issue; in general and/or specific populations.MethodsWe conducted a systematic review, by searching electronic databases including MEDLINE, EMBASE, Web of Science, CENTRAL and grey literature between 1960 and 2015. We included studies that reported modification of cardiovascular parameters or incidence/prevalence of cardiovascular outcomes, between a group of subjects exposed to HSCD relative to a non-exposed group. The threshold used to identify HSCD was 391 mg/day. We did not consider studies evaluating exposure to sodium as an active ingredient or those focusing on dialysis solutions or enteral/parenteral nutrition. Study quality was assessed using the EPHPP tool.ResultsA total of eight studies met our inclusion criteria. Four reported results for short-term exposure to HSCD (≤ 7 days) on BP fluctuations. One study reported an elevation of BP (associated sodium intake: 1,656 mg/day). Four studies evaluated a long-term exposure (≥ 2 years or discontinuation of a chronic treatment). Two studies reported iatrogenic risk. For these studies, drug associated sodium intake was high (> 1,500 mg/day) in patients with comorbidities (in particular, diabetes mellitus and hypertension).ConclusionDespite numerous study limitations, this systematic review suggests three potential synergistic risk factors for cardiovascular complications after exposure to HSCD: a high sodium intake (≥ 1,500 mg/day), a long duration of exposure, and the presence of comorbidities. Further studies are required to characterize this iatrogenic risk.Trial registrationPROSPERO CRD42016047086.
Background The use of a ‘do not interrupt’ vest during medication administration rounds is recommended but there have been no controlled randomized studies to evaluate its impact on reducing administration errors. We aimed to evaluate the impact of wearing such a vest on reducing such errors. The secondary objectives were to evaluate the types and potential clinical impact of errors, the association between errors and several risk factors (such as interruptions), and nurses’ experiences. Methods This was a multicenter, cluster, controlled, randomized study (March–July 2017) in 29 adult units (4 hospitals). Data were collected by direct observation by trained observers. All nurses from selected units were informed. A ‘Do not interrupt’ vest was implemented in all units of the experimental group. A poster was placed at the entrance of these units to inform patients and relatives. The main outcome was the administration error rate (number of Opportunities for Error (OE), calculated as one or more errors divided by the Total Opportunities for Error (TOE) and multiplied by 100). Results We enrolled 178 nurses and 1346 patients during 383 medication rounds in 14 units in the experimental group and 15 units in the control group. During the intervention period, the administration error rates were 7.09% (188 OE with at least one error/2653 TOE) for the experimental group and 6.23% (210 OE with at least one error/3373 TOE) for the control group (p = 0.192). Identified risk factors (patient age, nurses’ experience, nurses’ workload, unit exposition, and interruption) were not associated with the error rate. The main error type observed for both groups was wrong dosage-form. Most errors had no clinical impact for the patient and the interruption rates were 15.04% for the experimental group and 20.75% for the control group. Conclusions The intervention vest had no impact on medication administration error or interruption rates. Further studies need to be performed taking into consideration the limitations of our study and other risk factors associated with other interventions, such as nurse’s training and/or a barcode system. Trial registration The PERMIS study protocol (V2–1, 11/04/2017) was approved by institutional review boards and ethics committees (CPP Ile de France number 2016-A00211–50, CNIL 21/03/2017, CCTIRS 11/04/2016). It is registered at ClinicalTrials.gov (registration number: NCT03062852, date of first registration: 23/02/2017).
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