OBJECTIVES: The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials to investigate whether IV high-dose vitamin C improves the short-term mortality of patients with sepsis. DESIGN: This study is a systematic review and meta-analysis of randomized controlled trials. We searched EMBASE, the Cochrane Central Register of Controlled Trials, and MEDLINE for randomized controlled trials that met inclusion criteria. The protocol was registered at the University hospital Medical Information Network Clinical Trials Registry (UMIN000040528). All analyses were presented with the use of random-effects models. The primary outcome was short-term mortality defined as 28-day, 30-day, or in-hospital mortality. PATIENTS: Two authors independently evaluated the following eligibility criteria: 1) randomized controlled trial, 2) patients with sepsis aged ≥18 years, and 3) received intravenous high-dose vitamin C in addition to standard of care, or standard of care alone. Then, two authors independently extracted the selected patient and study characteristics and outcomes from studies that met above eligibility criteria. MEASUREMENTS AND MAIN RESULTS: Eleven randomized controlled trials (n = 1,737 patients) were included in this meta-analysis. High-dose IV vitamin C was not associated with a significantly lower short-term mortality (risk ratio, 0.88; 95% CI, 0.73–1.06; p = 0.18; I 2 = 29%) but was associated with a significantly shorter duration of vasopressor use (standardized mean difference, –0.35; 95% CI, –0.63 to –0.07; p < 0.01; I 2 = 80%) and a significantly greater decline in the Sequential Organ Failure Assessment score at 72–96 hours (standardized mean difference, –0.20; 95% CI, –0.32 to –0.08; p < 0.01; I 2 = 16%). One study reported significant association with hypernatremia, but adverse effects were rare, and high-dose vitamin C is deemed relatively safe. CONCLUSIONS: In this meta-analysis, the use of IV high-dose vitamin C in patients with sepsis was not associated with lower short-term mortality although it was associated with significantly shorter duration of vasopressor use and greater decline in the Sequential Organ Failure Assessment score at 72–96 hours.
Benign metastasizing leiomyoma is a rare disorder characterized by extrauterine growth of uterine leiomyoma. The true incidence is not well defined although it is often incidentally found in patients with a history of hysterectomy and leiomyoma. While histologically benign, its clinical behavior is similar to that of a sarcoma with most tumors found in the lung.
INTRODUCTION: Ketamine is a N-methyl-D-aspartate (NMDA) receptor antagonist that promotes bronchodilation through several mechanisms: blocking NDMA receptors to prevent bronchoconstriction, decreasing nitric oxide production in pulmonary tissues to reduce bronchospasm, and reducing inflammation to reverse histamine-induced bronchoconstriction. These properties suggest intravenous (IV) ketamine has a role in the management of status asthmaticus, particularly in refractory cases, but data remains limited.CASE PRESENTATION: Six patients (age 56 AE16 years, 33.3% female) receiving IV ketamine for status asthmaticus at a single center were identified through retrospective chart review. All six patients received nebulized bronchodilators, steroids, and magnesium prior to ketamine therapy, and required intubation. They were treated with IV ketamine bolus and infusion (ranging 0.5-2 mg/kg/hr). Pre and post treatment pH and CO2 improved overall (pH range 6.89-7.23 with mean 7.05 improving to 7.11-7.35, mean 7.21; pCO2 ranging 72-130 mm Hg with mean 98 decreasing to 30-78 mm Hg, mean 58). Two patients had recrudescence of symptoms with decreased tidal volumes (500 to 280 mL in one case, 580 to 420 mL in second case) and increased peak pressures after stopping the ketamine infusion without weaning. They improved with re-initiation and gradual weaning of ketamine infusion without further recurrence. Two other patients underwent gradual weaning of ketamine without recrudescence.DISCUSSION: In this single center, retrospective case series, IV ketamine was shown to demonstrate overall improvement in pH, pCO2. Only one patient had significant tachycardia and hypertension which improved with midazolam. Slow weaning of ketamine infusions seemed to prevent recurrence of symptoms in four of six patients receiving infusion, although two patients did not have recurrence of symptoms after abrupt discontinuation. CONCLUSIONS:In cases of refractory status asthmaticus, IV ketamine should be considered as an adjunctive therapy. Additional studies are needed to determine ideal infusion rates and weaning regimen before discontinuation.
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