The Safety and Utility of Phenobarbital Use for the Treatment of Severe Alcohol Withdrawal Syndrome in the Medical Intensive Care Unit.

BACKGROUND: Alcohol withdrawal syndrome (AWS) is a common reason for admission to a medical intensive care unit (MICU) and requires significant hospital resource utilization. Benzodiazepines are first-line therapy for AWS in many intensive care units. We propose the use of symptom-triggered phenobarbital for the treatment of AWS as a safe alternative to benzodiazepines. METHODS: This was a retrospective observational study of a 4-year period, 2011 to 2015, of all patients with AWS admitted to the MICU of 1 tertiary care hospital and treated with phenobarbital. A symptom-triggered protocol was used. Resolution of AWS was assessed with the Richmond Agitation Sedation Scale to goal score of 0 to -1. The Charlson Comorbidity Index was used as an index of patient illness severity. Complications associated with phenobarbital use and/or the AWS admission were analyzed. RESULTS: Data of 86 AWS patient encounters were analyzed. The mean Clinical Institute Withdrawal Assessment for Alcohol-Revised score of patients admitted to the MICU with AWS was 19 ± 9. The mean phenobarbital dose administered during the MICU stay was 1977.5 ± 1531.5 mg. There were a total of 17 (20%) intubations. The most frequent cause of mechanical ventilation in patients with AWS was loss of airway clearance, followed by hemodynamic instability secondary to upper gastrointestinal bleeding and the corresponding need for endoscopy. CONCLUSIONS: Sole use of phenobarbital use for control of AWS may be a safe alternative to benzodiazepines. Further study is needed to correlate phenobarbital serum levels with clinical control of AWS.

Risk of Nephrotoxicity Associated With Nonrenally Adjusted Intravenous Polymyxin B Compared to Traditional Dosing.

BACKGROUND: Polymyxin B's package insert recommends renal adjustment. Contemporary studies suggest it does not require renal adjustment. OBJECTIVE: To determine whether time to acute kidney injury (AKI) differs between renally adjusted and nonadjusted intravenous (IV) polymyxin B. METHODS: This retrospective chart review compared time to AKI after renally adjusted and nonadjusted IV polymyxin B administration. It included patients who were 18 years or older, received IV polymyxin B, and had creatinine clearance below 80 mL/min, and excluded ones who had AKI, received renal replacement therapy, or were pregnant. RESULTS: Fifty-four patients were included. There was not any statistical association between dosing type and time to AKI (P = .13). Incidence of nephrotoxicity, mortality, and length of stay (LOS) were higher in the renally adjusted arm (21.7% vs 6.5%, 17.4% vs 6.5%, and 16 vs 14 days, respectively). Four patients received concomitant ascorbic acid; not one developed AKI. CONCLUSION: A significant association between IV polymyxin B dosing type and time to AKI was not found. Adverse events were higher in the renally adjusted arm. This suggests that nonadjusted IV polymyxin B may be preferred in patients with renal impairment. Ascorbic acid may mitigate IV polymyxin B's nephrotoxic potential. Further studies are needed to corroborate these findings.

Feasibility, Utility, and Safety of Midodrine During Recovery Phase From Septic Shock.

BACKGROUND: We describe the feasibility, utility, and safety of oral midodrine to replace IV vasopressors during recovery from septic shock. METHODS: This was a retrospective study performed in a medical ICU. All study subjects had a diagnosis of septic shock requiring at least 24 hours of IV vasopressors and demonstrated clinical stability with stable or decreasing doses of IV vasopressors. The two groups compared were those who received IV vasopressors only and those who received IV vasopressors with adjunctive midodrine. RESULTS: Of the 275 study patients, 140 received an IV vasopressor only and 135 received midodrine in addition to an IV vasopressor. There was no difference between the groups' demographics (age, sex, Acute Physiology and Chronic Health Evaluation 4 score). Mean IV vasopressor duration was 3.8 days in the IV vasopressor only group and 2.9 days in the IV vasopressor with midodrine group (P < .001). An IV vasopressor was reinstituted after discontinuation in 21 of 140 (15%) patients in the IV vasopressor only group and in 7 of 135 (5.2%) patients in the IV vasopressor with midodrine group (P = .007). ICU length of stay was 9.4 days in the IV vasopressor only group and 7.5 days in the IV vasopressor with midodrine group (P = .017). There were no complications associated with midodrine use except transient bradycardia in one patient, which resolved upon discontinuation of midodrine. CONCLUSIONS: Midodrine may reduce the duration of IV vasopressors during recovery phase from septic shock and may be associated with a reduction in length of stay in the ICU.

The Integration of Technology into Treatment Programs to Aid in the Reduction of Chronic Pain.

In the United States, roughly $600 billion is spent on pain management - usually in the form of addictive opioid drugs. Due to the dangers associated with long-term opiate-based pain medication, the development of additional strategies for chronic pain management is warranted. The advent of smartphones and associated technology has provided healthcare providers with a unique opportunity to provide pain management support. This review summarizes of the use of technology to supplement chronic pain management regimens. Smartphone and internet-based applications that employ online journals facilitate improved communication between patient and clinician and allow for more personalized care and improved pain management. For instance, the e-Ouch application provides a platform for pain logs as well as feedback and coaching to patients via Twitter postings and blogs. Other applications provide online resources and blogs to improve patient education, which has shown to relieve patient symptoms through lifestyle modification. Internet-delivered cognitive behavioral therapy (CBT) focuses on the psychological coping mechanisms. The application of technology and smartphone apps toward pain management shows promise toward reducing the use of opioids in pain management, but has yet to be incorporated as a standard practice. More robust studies critically evaluating the efficacy of these technology-based therapies need to be conducted before standardization and insurance coverage can become reality.

Probe molecule spectroscopy of NaCl aerosol particle surfaces.

Excited-state absorption spectroscopy and ionization threshold measurements for coumarin 314 (C314) adsorbed to the surface of NaCl aerosols characterize the chemical environment of the particle surface as a function of relative humidity (RH). An atmospheric pressure flow of aerosol passes through an ionization cell where two-photon laser ionization of the adsorbed molecules produces a net charge on the particle. Monitoring this charge as a function of the laser wavelength produces either the absorption spectrum of the S(1) <-- S(0) transition or the ionization threshold. The wavelength of maximum absorption for the S(1) excited-state shifts from 448 nm for RH < 5% to 441 nm for RH = 60%, indicating that adsorbed water decreases the polarity of the surface. Similarly, the ionization threshold increases from 5.10 to 5.27 eV over a similar range of RH. The decrease in polarity is attributable to changes in the local electric field experienced by C314, which is on the order of 1 x 10(7) V/cm, and is correlated with changes in the surface topography. Using a continuum model, we estimate the contributions to the measured thresholds of the polarization response of the surface ions and the electric field and calculate an effective dielectric constant for the adsorbed water film. For a multilayer water coverage (RH = 65%), the effective dielectric constant is approximately 2.4. These results demonstrate that the changes in surface topography with adsorbed water are as important as direct water-solute interactions in determining the solvent character of the surface.